| (A) If the governmental entities transfer the maximum
amount of funds described in paragraph (1)(B) of this subsection,
the physician group practices will receive the maximum allowable payment
amounts for that period.
(B) If the governmental entities do not transfer the
maximum amount referenced in paragraph (1)(B) of this subsection,
each physician group practice in the pool will receive a portion of
its payment amount for that period, based on the physician group practice's
percentage of the total payment amounts for all providers in the pool
or sub-pool.
(i) Reconciliation. Data on the uncompensated-care
physician application will be used to reconcile actual costs incurred
by the physician group practice for a prior period with uncompensated-care
payments, if any, made to the physician group practice for the same
period.
(1) If a physician group practice received payments
in excess of its actual costs, the overpaid amount will be recouped
from the physician group practice, as described in subsection (j)
of this section.
(2) If a physician group practice received payments
less than its actual costs, and if HHSC has available waiver funding
for the period in which the costs were accrued, the physician group
practice may receive reimbursement for some or all of those actual
documented unreimbursed costs.
(j) Recoupment.
(1) In the event of a disallowance by CMS of federal
financial participation related to a physician group practice's receipt
or use of payments under this section, HHSC may recoup an amount equivalent
to the amount of the overpayment or disallowance. The non-federal
share of any funds recouped from the physician group practice will
be returned to the entity that owns or is affiliated with the physician
group practice.
(2) Payments under this section may be subject to adjustment
for payments made in error, including, without limitation, adjustments
under §371.1711 of this title (relating to Recoupment of Overpayments
and Debts), 42 CFR Part 455, and Chapter 403 of the Texas Government
Code. HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid
payments as follows.
(A) HHSC will recoup from the physician group practice
against which any disallowance was directed or to which an overpayment
was made.
(B) If within 30 days of the physician group practice's
receipt of HHSC's written notice of recoupment, the physician group
practice has not paid the full amount of the recoupment or entered
into a written agreement with HHSC to do so, HHSC may withhold any
or all future Medicaid payments from the physician group practice
until HHSC has recovered an amount equal to the amount overpaid or
disallowed.
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