Sec. 531.1131. FRAUD AND ABUSE RECOVERY BY CERTAIN PERSONS; RETENTION OF RECOVERED AMOUNTS. (a) If a managed care organization or an entity with which the managed care organization contracts under Section 531.113(a)(2) discovers fraud or abuse in Medicaid or the child health plan program, the organization or entity shall:
(1) immediately submit written notice to the commission's office of inspector general and the office of the attorney general in the form and manner prescribed by the office of inspector general and containing a detailed description of the fraud or abuse and each payment made to a provider as a result of the fraud or abuse;
(2) subject to Subsection (b), begin payment recovery efforts; and
(3) ensure that any payment recovery efforts in which the organization engages are in accordance with applicable rules adopted by the executive commissioner.
(b) If the amount sought to be recovered under Subsection (a)(2) exceeds $100,000, the managed care organization or the contracted entity described by Subsection (a) may not engage in payment recovery efforts if, not later than the 10th business day after the date the organization or entity notified the commission's office of inspector general and the office of the attorney general under Subsection (a)(1), the organization or entity receives a notice from either office indicating that the organization or entity is not authorized to proceed with recovery efforts.
(c) A managed care organization may retain one-half of any money recovered under Subsection (a)(2) by the organization or the contracted entity described by Subsection (a). The managed care organization shall remit the remaining amount of money recovered under Subsection (a)(2) to the commission's office of inspector general for deposit to the credit of the general revenue fund.
(c-1) If the commission's office of inspector general notifies a managed care organization under Subsection (b), proceeds with recovery efforts, and recovers all or part of the payments the organization identified as required by Subsection (a)(1), the organization is entitled to one-half of the amount recovered for each payment the organization identified after any applicable federal share is deducted. The organization may not receive more than one-half of the total amount of money recovered after any applicable federal share is deducted.
(c-2) Notwithstanding any provision of this section, if the commission's office of inspector general discovers fraud, waste, or abuse in Medicaid or the child health plan program in the performance of its duties, the office may recover payments made to a provider as a result of the fraud, waste, or abuse as otherwise provided by this subchapter. All payments recovered by the office under this subsection shall be deposited to the credit of the general revenue fund.
(c-3) The commission's office of inspector general shall coordinate with appropriate managed care organizations to ensure that the office and an organization or an entity with which an organization contracts under Section 531.113(a)(2) do not both begin payment recovery efforts under this section for the same case of fraud, waste, or abuse.
(d) A managed care organization shall submit a quarterly report to the commission's office of inspector general detailing the amount of money recovered under Subsection (a)(2).
(e) The executive commissioner shall adopt rules necessary to implement this section, including rules establishing due process procedures that must be followed by managed care organizations when engaging in payment recovery efforts as provided by this section.
(f) In adopting rules establishing due process procedures under Subsection (e), the executive commissioner shall require that a managed care organization or an entity with which the managed care organization contracts under Section 531.113(a)(2) that engages in payment recovery efforts in accordance with this section and Section 531.1135 provide:
(1) written notice to a provider required to use electronic visit verification of the organization's intent to recoup overpayments in accordance with Section 531.1135; and
(2) a provider described by Subdivision (1) at least 60 days to cure any defect in a claim before the organization may begin any efforts to collect overpayments.
Added by Acts 2011, 82nd Leg., R.S., Ch. 980 (H.B. 1720), Sec. 7, eff. September 1, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.152, eff. April 2, 2015.
Acts 2017, 85th Leg., R.S., Ch. 277 (H.B. 2379), Sec. 6, eff. May 29, 2017.
Acts 2019, 86th Leg., R.S., Ch. 667 (S.B. 1991), Sec. 2, eff. September 1, 2019.
Structure Texas Statutes
Subtitle I - Health and Human Services
Chapter 531 - Health and Human Services Commission
Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges
Section 531.101. Award for Reporting Medicaid Fraud, Abuse, or Overcharges
Section 531.102. Office of Inspector General
Section 531.1022. Peace Officers
Section 531.1023. Compliance With Federal Coding Guidelines
Section 531.1024. Hospital Utilization Reviews and Audits: Provider Education Process
Section 531.1025. Performance Audits and Coordination of Audit Activities
Section 531.103. Interagency Coordination
Section 531.1031. Duty to Exchange Information
Section 531.1032. Office of Inspector General: Criminal History Record Information Check
Section 531.1033. Monitoring of Certain Federal Databases
Section 531.1034. Time to Determine Provider Eligibility; Performance Metrics
Section 531.104. Assisting Investigations by Attorney General
Section 531.105. Fraud Detection Training
Section 531.106. Learning, Neural Network, or Other Technology
Section 531.1061. Fraud Investigation Tracking System
Section 531.1062. Recovery Monitoring System
Section 531.108. Fraud Prevention
Section 531.1081. Integrity of Certain Public Assistance Programs
Section 531.109. Selection and Review of Claims
Section 531.110. Electronic Data Matching Program
Section 531.111. Fraud Detection Technology
Section 531.113. Managed Care Organizations: Special Investigative Units or Contracts
Section 531.1131. Fraud and Abuse Recovery by Certain Persons; Retention of Recovered Amounts
Section 531.1132. Annual Report on Certain Fraud and Abuse Recoveries
Section 531.1135. Managed Care Organizations: Process to Recoup Certain Overpayments
Section 531.114. Financial Assistance Fraud
Section 531.115. Federal Felony Match
Section 531.116. Compliance With Law Prohibiting Solicitation
Section 531.117. Recovery Audit Contractors
Section 531.118. Preliminary Investigations of Allegations of Fraud or Abuse and Fraud Referrals
Section 531.119. Website Posting
Section 531.120. Notice and Informal Resolution of Proposed Recoupment of Overpayment or Debt
Section 531.1201. Appeal of Determination to Recoup Overpayment or Debt
Section 531.1202. Record and Confidentiality of Informal Resolution Meetings
Section 531.1203. Rights of and Provision of Information to Pharmacies Subject to Certain Audits