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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.10 Medicaid Waste, Abuse, and Fraud Policy : 1.10.4 Managed Care Organization (MCO) Special Investigative Unit (SIU)

1.10.4
All MCOs that contract with HHSC to administer managed care benefits to Texas Medicaid clients are required to establish and maintain an SIU that works in cooperation with HHSC-OIG and the OAG.
Refer to:
The MCO and SIU will do the following:
The established SIU will identify and investigate cases of suspected waste, abuse, and fraud in Texas Medicaid in accordance with Title 1, Chapter 353, Subchapter F of the TAC.
An annual plan that has been adopted by the MCO and approved by HHSC-OIG describing how it will prevent and reduce fraud and abuse in accordance with 1 TAC, §§353.501 and 353.502.
The MCO will refer a case to both HHSC-OIG and MFCU in the following situations:
When waste, abuse or fraud is discovered in the Medicaid or CHIP programs. (The MCO SIU must immediately notify the HHSC-OIG and MFCU and begin payment recovery efforts, unless HHSC-OIG or MFCU notifies the MCO to stop the recovery effort, as provided in Texas Government Code §531.1131.)
When possible waste, abuse, or fraud is discovered in the Medicaid or CHIP programs. (The MCO SIU must refer the alleged fraud or abuse to HHSC-OIG within 30 working days of completing a review. The SIU report and referral must completely and accurately detail its findings in accordance with 1 TAC §353.502.)

Texas Medicaid & Healthcare Partnership
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