SECTION 371.1701. Administrative Actions

(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.

Source Note: The provisions of this §371.1701 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective May 1, 2016, 41 TexReg 2941