| (F) Educate recipients, providers, and employees about
their responsibilities, the responsibility of others, the definition
of waste, abuse, and fraud and how and where to report it. Appropriate
methods of educating recipients, providers, and employees may include
but are not limited to newsletters, pamphlets, bulletins, and provider
(G) The MCOs will maintain a training log for all training
pertaining to waste, abuse, and/or fraud in Medicaid. The log must
include the name and title of the trainer, names of all staff attending
the training, and the date and length of the training. The log must
be provided immediately upon request to the HHSC-OIG, Office of the
Attorney General's (OAG)-Medicaid Fraud Control Unit (MFCU) and OAG-Civil
Medicaid Fraud Division (CMFD), and the United States Health and Human
Services-Office of Inspector General (HHS-OIG).
(H) Written standards of conduct, and written policies
and procedures that include a clearly delineated commitment from the
MCOs for detecting, preventing and investigating waste, abuse, and
(7) The name, title, address, telephone number, and
fax number of the assigned officer or director responsible for carrying
out the plan.
(A) The person carrying out the plan should be but
is not limited to a Compliance Officer, a Manager of Government Programs,
Regulatory Compliance Analyst, Director of Quality Integrity, or a
person in senior management.
(B) When the person that is responsible for carrying
out the plan changes, the required information is to be reported to
HHSC-OIG within 15 working days of the change.
(8) A description, process flow diagram, or chart outlining
the organizational arrangement of the MCO's personnel responsible
for investigating and reporting possible acts of waste, abuse, or
(9) Advertising and marketing materials utilized by
the MCOs must be complete and accurately reflect the information about
the MCO. Marketing materials includes any informational materials
targeted to recipients.
(d) Each MCO must satisfy the requirements in paragraphs
(1) - (3) of this subsection related to investigations of waste, abuse,
and fraud conducted by the MCO's SIU.
(1) On a monthly basis, submit to the HHSC-OIG a report
listing all investigations conducted that resulted in no findings
of waste, abuse, or fraud. The report must include the allegation,
the investigated recipient's or provider's Medicaid number, the source,
the time period in question, and the date of receipt of the identification
and/or reporting of suspected and/or potential waste, abuse, or fraud.
(2) Maintain a log of all incidences of suspected waste,
abuse and fraud received by the MCO regardless of the source. The
log must contain the subject of the complaint, the source, the allegation,
the date the allegation was received, the recipient's or provider's
Medicaid number, and the status of the investigation.
(3) The log should be provided at the time of a reasonable
request to the HHSC-OIG, OAG-MFCU, OAG-CMFD, and the HHS-OIG. A reasonable
request means a request made during hours that the business or premises
is open for business.
(e) MCOs must maintain the confidentiality of any patient
information relevant to an investigation of waste, abuse, or fraud.
(f) MCOs must retain records obtained as the result
of an investigation conducted by the SIU for a minimum period of five
years or until all audit questions, appealed hearings, investigations,
or court cases are resolved.
(g) Failure of the provider to supply the records requested
by the MCO will result in the provider being reported to the HHSC-OIG
as refusing to supply records upon request and the provider may be
subject to sanction or immediate payment hold.