SECTION 357.622. Recovery from Providers

(a) Overpayments involving possible fraud are referred to the Attorney General's Fraud Control Unit. If intent to defraud is not determined or cannot be proven, the department or its agents may take an administrative sanction to recoup overpayments. Recovery of the overpayments from a provider who made a false statement or misrepresentation, or who omitted pertinent facts may include the cumulative dollar amount due. The following situations are not intended to be all inclusive.

(1) An ordering provider causes an overpayment to be made to himself or to another provider as a result of a false statement, misrepresentation, or omission of pertinent facts on a claim, attachments to a claim, medical records, or any other documentation used to adjudicate a claim for payment; any documentation submitted or maintained by the provider to support payment on individual claims or to support representations made on cost reports; or other documents used to establish fees, daily payment rates, or vendor payments.

(2) A provider makes a false statement, a misrepresentation, or omits pertinent facts on a provider agreement or any documents required as a prerequisite for Medicaid participation.

(b) Medicaid Fraud Control Unit is primarily responsible for obtaining and reporting restitution in fraud court cases. If a particular case involves both judicial and administrative processes, the judicial process takes precedence. The unit is responsible for arranging repayment terms in fraud cases of court-ordered restitution. The department may take any other administrative sanction or action pertinent to the violation.

(c) The department may recover funds when no actual overpayment was made. The following instances are not intended to be all inclusive:

(1) recover of a patient's trust fund money for distribution to appropriate recipients or their responsible parties if those funds were misapplied, misused, or embezzled; or the provider is required to make this distribution;

(2) recovery of funds previously collected by the provider from recipients if collection is not allowed by contract, statute, regulation, rules, provider policy or procedure manuals, published Medicaid bulletins, policy notification letters, or interpretations previously sent to the provider;

(3) recovery of the cost of a contract appeals hearing from the provider if the department's action is upheld by the final decision of the contract appeals committee. For the purpose of this paragraph, cost of a contract appeals hearing is defined as the total cost for the court reporter and any transcripts and copies developed in preparation for, during, or after the hearing; and

(4) recovery of an unpaid debt plus interest, if any, owed to any state Medicaid or Medicare program as the result of fraudulent or abusive actions by the provider. The department distributes the balance of the recovered amount to the state Medicaid or Medicare program after recovering any administrative costs associated with the recovery. Any appeal by the provider is based solely upon whether there is or is not an unpaid balance owed to the state Medicaid or Medicare program in question.

Source Note: The provisions of this §357.622 adopted to be effective July 1, 1986, 11 TexReg 2828; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013