SECTION 371.1311. Role of the OIG and SIUs

(a) An MCO is required by §353.502 of this title (relating to Managed Care Organization's Plans and Responsibilities in Preventing and Reducing Waste, Abuse, and Fraud) and §370.501 of this title (relating to Purpose) to establish and maintain an SIU to investigate allegations of waste, abuse, or fraud for all services in the MCO plan. If an MCO suspects possible waste, abuse, or fraud, the MCO must conduct a preliminary investigation in accordance with criteria in §353.502 and §370.501 of this title. If the preliminary investigation confirms waste, abuse, or fraud, the MCO must refer the matter to the OIG in accordance with §353.505 of this title (relating to Recovery of Funds).

(b) For a potential overpayment amount less than $100,000, the MCO pursues recovery of the overpayment, and remits one-half of the recovered amount in accordance with §353.505 of this title (relating to Recovery of Funds).

(c) For MCO referrals to the OIG where the potential overpayment amount exceeds $100,000, the OIG accepts the referral and conducts a preliminary investigation.

(1) The OIG evaluates the allegation(s) and evidence from the MCO-SIU for intentional deception, repeat billing pattern, or other indicators of questionable practices.

(2) The OIG determines within 30 business days whether to take additional investigative action, and notifies the referring MCO of the decision.

(d) If the preliminary investigation determines a full investigation is warranted, the OIG assesses the provider's billing activity in fee-for-service Medicaid and other MCOs in which the provider is credentialed.

Source Note: The provisions of this §371.1311 adopted to be effective May 1, 2016, 41 TexReg 2941; amended to be effective July 18, 2019, 44 TexReg 3544