1 Tex. Admin. Code § 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.

Notes

1 Tex. Admin. Code § 371.1701

The provisions of this §371.1701 adopted to be effective October 14, 2012, 37 TexReg 7989; Amended by Texas Register, Volume 41, Number 17, April 22, 2016, TexReg 2945, eff. 5/1/2016