(a) The OIG may impose one or more administrative actions
if it determines that the person committed an act for which a person
is subject to administrative actions or sanctions, including the following:
(1) commits a program violation;
(2) commits an act for which sanctions, damages, penalties,
or liability could be or are assessed by the OIG;
(3) commits an act that amounts to fraud, abuse, overpayment,
or waste in relation to Medicaid or an HHS program or service; or
(4) is affiliated with a person who commits an act
described in paragraphs (1) - (3) of this subsection.
(b) An administrative action may be taken in conjunction
with or independently of other enforcement measures, and is not a
prerequisite to the imposition of a sanction or other enforcement
measure.
(c) Administrative actions include:
(1) transferring a person to a closed-end contract
or agreement for a specified period of time or to a provisional or
probationary contract or agreement with modified terms and conditions;
(2) attendance at education sessions;
(3) prior authorization of selected services (failure
to submit and receive prior authorization prior to the service being
rendered or billed would result in denial of the claim);
(4) prepayment review of all claims or certain specific
claims or services of a person;
(5) conducting post-payment review of all claims or
certain specific claims or services of a person after payment;
(6) attendance at informal or formal person corrective
action meetings;
(7) requiring submission of additional documentation
or justification for a claim, as deemed advisable by the OIG, as a
condition precedent to payment of the claim;
(8) oral, written, or personal educational contact
with the person;
(9) requiring a person to post a surety bond or provide
a letter of credit, as provided in §371.23 of this chapter (relating
to Surety Bond);
(10) serving a subpoena to compel the production of
a witness or of relevant evidence;
(11) reinstatement; and
(12) referral for additional review or investigation
of any person suspected of committing fraud, waste, or abuse. Such
referrals include the following entities:
(A) all cases of suspected Medicaid fraud or patient
abuse or neglect to the OAG Medicaid Fraud Control Unit or Civil Medicaid
Fraud Division for investigation;
(B) peer review outside HHSC or operating agency;
(C) the appropriate state licensing board;
(D) the United States Department of Health and Human
Services, including for action under the Civil Monetary Penalties
Law (the Social Security Act, §1128);
(E) other federal or state law enforcement agencies
for fraud investigation and criminal fraud prosecution;
(F) other federal or state agencies for civil fraud
prosecution and imposition of civil damages or penalties or recovery
of overpayments and administrative penalties and damages through judicial
means;
(G) a collection agency, the OAG, or any other collection
authority, for recovery of overpayments, administrative penalties
and damages or other debts established by the OIG;
(H) credit bureaus for failure to pay all imposed recoupments
and damages and penalties; and
(I) any other entity determined to be advisable or
necessary by the OIG.
(d) The OIG provides written notice of the administrative
actions described in subsection (c)(1) - (11) of this section to persons
who are the subject of administrative actions. The notice includes:
(1) a description of the administrative action;
(2) the general basis for the administrative action;
and
(3) a description of what the person must do to comply
with the administrative action.
(e) An administrative action does not give rise to
due process, additional notice, or hearing requirements.
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