| (ii) A requirement that possible acts of waste, abuse,
or fraud be reported to the assigned officer or director must occur
within 15 working days of making the determination.
(D) Within 30 working days of the completion of the
SIU investigation and receiving reports of possible acts of waste,
abuse, or fraud from the SIU, the assigned officer or director must
notify and refer all possible acts of waste, abuse or fraud to the
HHSC-OIG. All reports and referrals of possible acts of waste, abuse,
and fraud, with the exception of an expedited referral, must include
the following information related to the referrals:
(i) the provider's enrollment/credentialing documents;
(ii) the complete SIU investigative file on the provider,
which must include:
(I) an investigative report identifying the allegation,
statutes/regulations/rules violated or considered, and the results
of the investigation;
(II) the estimated overpayment identified;
(III) a summary of interviews conducted; and
(IV) a list of all claims and associated overpayments
identified by the preliminary investigation;
(iii) a summary of all past investigations of the provider
conducted by the MCO or the MCO's SIU. Upon request, the MCO shall
provide the complete investigative files or any other information
regarding those past investigations to the HHSC-OIG investigator;
(iv) copies of HHSC program and MCO policy, contract,
and other requirements, as well as statutes/regulations/rules, alleged
to be violated for the time period in question;
(v) all education letters (including education documents)
and/or recoupment letters issued to the provider by the MCO or the
MCO's SIU at any time;
(vi) all medical records;
(vii) all clinical review reports/summaries generated
by the MCO;
(viii) any and all correspondence and/or communications
between the MCO, the MCO's subcontractors, and any of their employees,
contractors, or agents, and the provider related to the investigation.
This should include but not be limited to agents, servants and employees
of the MCO, regardless of whether those agents, servants and employees
are part of the SIU who investigated the provider;
(ix) copies of all settlement agreements between the
MCO and its contractors and the provider; and
(x) if the referral contains fewer recipients or claims
than the minimum described in paragraph (2)(C) of this subsection,
a written justification for the decision to substantiate the waste,
abuse, or fraud with fewer recipients or claims. The justification
will be subject to review and approval by HHSC-OIG, who may require
the MCO to provide further information.
(E) An expedited referral is required when the MCO
has reason to believe that a delay may result in:
(i) harm or death to patients
(ii) the loss, destruction, or alteration of valuable
evidence; or
(iii) a potential for significant monetary loss that
may not be recoverable; or
(iv) hindrance of an investigation or criminal prosecution
of the alleged offense.
(6) A description of the MCO's procedures for educating
recipients and providers and training personnel to prevent waste,
abuse, and fraud. The procedures must satisfy the requirements in
subparagraphs (A) - (H) of this paragraph.
(A) On an annual basis, the MCO must ensure that waste,
abuse, and fraud training is provided to each employee and subcontractor
who is directly involved in any aspect of Medicaid. At a minimum,
training is required for all individuals responsible for data collection,
provider enrollment or disenrollment, encounter data, claims processing,
utilization review, appeals or grievances, quality assurance, and
marketing.
(B) The training must be specific to the area of responsibility
for the MCO and subcontractor staff receiving the training and contain
examples of waste, abuse, or fraud in their particular area of interest.
(C) The MCO must ensure that general training is provided
to all Medicaid managed care staff of the MCO and its subcontractors
who are not directly involved with the areas listed in subparagraph
(A) of this paragraph. The general training must provide information
about the definition of waste, abuse, and fraud; how to report suspected
waste, abuse, and fraud; and to whom the suspected waste, abuse, and
fraud is reported.
(D) The organization must provide waste, abuse, and
fraud training to all new MCO and subcontractor staff that will be
directly involved with any aspect of Medicaid within 90 days of the
employee's employment date.
(E) Provide updates to all affected areas when changes
to policy and/or procedure may affect their area(s). The updates must
be provided within 20 working days of the changes occurring.
(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
manuals.
(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
fraud.
(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
fraud.
(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.
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