SECTION 371.33. On-Site Reviews of Prospective Providers

(a) The Inspector General may implement procedures targeted at minimizing the potential for fraud, abuse, false statements, misrepresentations, and omissions by prospective Medicaid and other HHS providers. The Inspector General may conduct on-site reviews of providers who have applied to provide services to recipients.

(b) On-Site Review Criteria and Effect.

(1) During its on-site review, the Inspector General will determine whether or not an applicant has the ability to provide the services proposed within its application. To make this determination, personnel will conduct the inspections and interviews set forth in subsection (c) of this section (relating to Scope of Review), and evaluate information gathered thereby within the context of applicable industry standards, including state or federal governmental licensing and/or certification standards that apply to the applicant under review.

(2) In the event an on-site review reveals that a provider is not capable of delivering the services proposed within its application or develops other evidence of fraud, abuse, false statements, misrepresentations, or omissions, the application may be denied. The Inspector General also may forward to the Attorney General or other appropriate law enforcement agency any information discovered during an on-site review that the Inspector General believes warrants further evaluation in a law enforcement context.

(c) Scope of Review.

(1) Inspections and interviews. During on-site reviews, Inspector General personnel may:

(A) inspect a provider's site for physical compliance with state and federal law governing Medicaid or other HHS providers;

(B) review and verify licenses, certifications, and accreditation required by or relevant to the Medicaid or other HHS programs;

(C) interview randomly selected provider staff-members, patients, and patients' family members;

(D) review randomly selected Medicaid and other HHS agency patients' medical records;

(E) review business records, as determined necessary by the Inspector General, of prospective provider; and

(F) verify any and all items in the application for participation, contract, provider agreement, or any other documents supplied for purposes of provider enrollment.

(2) Personnel shall conduct all interviews during on-site reviews in accordance with a standard format consistent with interview procedures established for survey and investigation of existing Medicaid and other HHS providers.

Source Note: The provisions of this §371.33 adopted to be effective January 9, 2005, 29 TexReg 12128