SECTION 371.1307. Full Investigation

(a) The OIG begins a full investigation within 30 days of completing the preliminary investigation if it determines that a full investigation is warranted.

(b) The OIG may close a full investigation for one or more of the following reasons, if the OIG determines that:

(1) the investigative research and evidence gathered during the full investigation indicates that fraud, waste, or abuse is not present;

(2) there is no violation of Medicaid policy;

(3) there is no overpayment to recover;

(4) the potential identified overpayment is not cost-effective to pursue;

(5) the issues related to the complaint are outside of OIG jurisdiction;

(6) a referral to the appropriate licensure or oversight agency is deemed a more appropriate action;

(7) the case should be referred to another division of OIG for action;

(8) the provider should receive education;

(9) the Medicaid provider is deceased or out of business; or

(10) no administrative action, sanction, or overpayment is appropriate after weighing the following factors:

(A) the seriousness of the allegations and potential program violations;

(B) the investigative resources available to pursue the full investigation; and

(C) the sufficiency and strength of evidence gathered in the full investigation.

(c) A full investigation must be completed within 180 days unless the OIG determines that more time is needed to complete the investigation.

(d) If the OIG determines that more time is needed to complete the investigation, the OIG must notify the provider who is the subject of the investigation indicating that the investigation will exceed 180 days and specifying the reasons the OIG is unable to complete the investigation within the 180-day time period. However, the OIG is not required to notify the provider if the OIG determines that notice would jeopardize the investigation.

(e) Within 30 days of completion of the preliminary investigation, the OIG refers the case to the state's Medicaid fraud control unit if a provider is suspected of fraud, waste, or abuse involving criminal conduct or if the OIG learns or has reason to suspect that a provider's records are being withheld, concealed, destroyed, fabricated, or in any way falsified. This referral does not preclude the OIG from continuing its investigation of the provider.

Source Note: The provisions of this §371.1307 adopted to be effective April 15, 2014, 39 TexReg 2833; amended to be effective May 1, 2016, 41 TexReg 2941; amended to be effective July 23, 2019, 44 TexReg 3628