A person is subject to administrative action or sanctions if
the person:
(1) is an MCO or an MCO provider and fails to provide
a health care benefit, service, or item that the MCO or MCO provider
is required to provide according to the terms of its contract with
an operating agency, its fiscal agent, or other contractor to provide
health care services to Medicaid or HHS program recipients;
(2) is an MCO or MCO provider and fails to provide
to an individual a health care benefit, service, or item that the
MCO or MCO provider is required to provide by state or federal law,
regulation, or program rule;
(3) is an MCO and engages in actions that indicate
a pattern of wrongful denial, excessive delay, barriers to treatment,
authorization requirements that exceed professionally recognized standards
of health care, or other wrongful avoidance of payment for a health
care benefit, service or item that the organization is required to
provide under its contract with an operating agency;
(4) is an MCO and engages in actions that cause a delay
in making payment for a health care benefit, service or item that
the organization is required to provide under its contract with an
operating agency, and the delay results in processing or paying the
claim on a date later than that allowed by the MCO's contract;
(5) is an MCO or MCO provider and engages in fraudulent
activity or misrepresents or omits material facts in connection with
the enrollment in the MCO's managed care plan of an individual eligible
for medical assistance or in connection with marketing the organization's
services to an individual eligible for medical assistance;
(6) is an MCO or MCO provider and receives a capitation
payment, premium, or other remuneration after enrolling a member in
the MCO's managed care plan whom the MCO knows or should have known
is not eligible for medical assistance;
(7) is an MCO or MCO provider and discriminates against
MCO-enrollees or prospective MCO-enrollees in any manner, including
marketing and disenrollment, and on any basis, including, without
limitation, age, gender, ethnic origin, or health status;
(8) is an MCO or MCO provider and fails to comply with
any term of a contract with a Medicaid or other HHS program or operating
agency or other contract to provide health care services to Medicaid
or HHS program recipients and the failure leads to patient harm, creates
a risk of fiscal harm to the state, or results in fiscal harm to the
state;
(9) is an MCO or an MCO provider and fails to provide,
in the form requested, to the relevant operating agency or its authorized
agent upon written request, accurate encounter data, accurate claims
data, or other information contractually or otherwise required to
document the services and items delivered by or through the MCO to
recipients;
(10) is an MCO or an MCO provider and files a cost
report or other report with the Medicaid or other HHS program that
violates any of the cost report violations in §371.1665 of this
division (relating to Cost Report Violations);
(11) is an MCO or MCO provider and misrepresents, falsifies,
makes a material omission, or otherwise mischaracterizes any facts
on a request for proposal, contract, report, or other document with
respect to the MCO's ownership, provider network, credentials of the
provider network, affiliated persons, solvency, special investigative
unit, plan for detecting and preventing fraud, waste, or abuse, or
any other material fact;
(12) is an MCO or MCO provider and fails to maintain
the criteria and conditions supporting an application and grant of
a waiver to HHSC, or fails to demonstrate the results that were contemplated,
based upon representations by the MCO or provider in its proposal
submissions or contract negotiations when the waiver was granted,
if the failure is related to representations made by the MCO in its
proposal, readiness review, contract, marketing materials, audit management
responses, or other written representation submitted to the state,
and the failure leads to patient harm, creates a risk of fiscal harm
to the state, or results in fiscal harm to the state;
(13) is an MCO or MCO provider and misrepresents, falsifies,
makes a material omission, or otherwise mischaracterizes any facts
on a patient assessment or any other document that would have the
effect of increasing the MCO's capitation or reimbursement rate, would
increase incentive payments or premiums, would decrease the amount
of capitation at risk, or would decrease the experience rebate owed
to the Medicaid program;
(14) is an MCO or MCO provider and fails to simultaneously
notify the OIG and the OAG in writing of the discovery of fraud, waste,
or abuse in the Medicaid or CHIP program;
(15) is an MCO and fails to ensure that any payment
recovery efforts in which the MCO engages are in accordance with applicable
law, contract requirements, or other applicable procedures established
by the Executive Commissioner or the OIG;
(16) is an MCO and engages in payment recovery of an
amount sought that exceeds $100,000 and that is related to fraud,
waste, or abuse in the Medicaid or CHIP program:
(A) without first notifying the OIG and the OAG in
writing of the discovery of fraud, waste, or abuse in the Medicaid
or CHIP program;
(B) within ten business days after notifying the OIG
or the OAG of the discovery or fraud, waste, or abuse in the Medicaid
or CHIP program; or
(C) after receipt of a notice from the OIG or the OAG
indicating that the MCO is not authorized to proceed with recovery
efforts;
(17) is an MCO and fails to timely submit an accurate
monthly report to the OIG detailing the amount of money recovered
after any and all payment recovery efforts engaged in as a result
of the discovery of fraud, waste, or abuse in the Medicaid or CHIP
program;
(18) notwithstanding the terms of any contract, is
an MCO or MCO provider and fails to timely comply with the requirements
of the Texas Medicaid Managed Care program or with the terms of the
MCO contract with HHSC or other contract to provide health care services
to Medicaid or HHS program recipients, and the failure leads to patient
harm, creates a risk of fiscal harm to the state, or results in fiscal
harm to the state;
(19) is an MCO or MCO provider and engages in marketing
services in violation of §531.02115 of the Texas Government Code,
the program rules or contract and has not received prior authorization
from the program for the marketing campaign;
(20) is an MCO or an MCO provider and fails to use
prior authorization and utilization review processes to reduce authorizations
of unnecessary services and inappropriate use of services;
(21) is an MCO or MCO provider and commits or conspires
to commit a violation of §32.039(b) of the Texas Human Resources
Code;
(22) is an MCO and fails to implement or release a
payment hold as directed by the OIG or to report accurate payment
hold amounts to the OIG;
(23) is an MCO and fails to comply with any provision
in Chapter 353, Subchapter F of this title (relating to Special Investigative
Units) or Chapter 370, Subchapter F of this title (relating to Special
Investigative Units); or
(24) is an MCO and releases information pertaining
to an OIG investigation of a provider.
|
