Sec. 531.1131. FRAUD AND ABUSE RECOVERY BY CERTAIN PERSONS; RETENTION OF RECOVERED AMOUNTS. (a) If a managed care organization's special investigative unit under Section 531.113(a)(1) or the entity with which the managed care organization contracts under Section 531.113(a)(2) discovers fraud or abuse in Medicaid or the child health plan program, the unit or entity shall:
(1) immediately and contemporaneously notify the commission's office of inspector general and the office of the attorney general;
(2) subject to Subsection (b), begin payment recovery efforts; and
(3) ensure that any payment recovery efforts in which the organization engages are in accordance with applicable rules adopted by the executive commissioner.
(b) If the amount sought to be recovered under Subsection (a)(2) exceeds $100,000, the managed care organization's special investigative unit or contracted entity described by Subsection (a) may not engage in payment recovery efforts if, not later than the 10th business day after the date the unit or entity notified the commission's office of inspector general and the office of the attorney general under Subsection (a)(1), the unit or entity receives a notice from either office indicating that the unit or entity is not authorized to proceed with recovery efforts.
(c) A managed care organization may retain any money recovered under Subsection (a)(2) by the organization's special investigative unit or contracted entity described by Subsection (a).
(d) A managed care organization shall submit a quarterly report to the commission's office of inspector general detailing the amount of money recovered under Subsection (a)(2).
(e) The executive commissioner shall adopt rules necessary to implement this section, including rules establishing due process procedures that must be followed by managed care organizations when engaging in payment recovery efforts as provided by this section.
Added by Acts 2011, 82nd Leg., R.S., Ch. 980 (H.B. 1720), Sec. 7, eff. September 1, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.152, eff. April 2, 2015.
Section: Previous 531.108 531.109 531.110 531.111 531.1112 531.112 531.113 531.1131 531.1132 531.114 531.115 531.116 531.117 531.118 531.119 NextLast modified: September 28, 2016