The Office of Inspector General has another proposed rule on the Texas HHS “Comment on Proposed and Draft Rules” webpage entitled – “Recoupment of Overpayments Identified by Retrospective Payment Review.”
This one is another addition to the Texas Administrative Code relating to Chapter 371 “MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY.”
Result of survey of MCOs & DMOs
These new rules are apparently the result of a survey that OIG did back in 2022 of all 20 MCOs and dental maintenance organizations (DMOs) participating in Texas Medicaid and the Children’s Health Insurance Program (CHIP). This is explained in an OIG news release on its website:
Respondents were asked about the use and effectiveness of various cost avoidance activities. In the review, the OIG found MCOs implement measures to promote program integrity that fall into three broad categories: prepayment reviews, post-payment reviews and potentially preventable events:
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- Prepayment review strategies focus on preventing improper payments to providers by identifying and denying claims that contain billing errors before they reach the claims system, reviewing accepted claims before payments are processed and preventing payments for improperly coded heath care services.
- Post-payment reviews occur after a provider has been paid. However, reviewing the activity prevents future FWA. For example, duplicate payment detection is a data-driven strategy that allows MCOs to recover or even prevent payments to providers claiming the same service for the same patient.
- Post-payment review strategies also include analyzing data and implementing interventions for prospective cost savings.
This new rule is very similar in wording to the previous one we recently reported.
Deadline for comment is August 24
Providers have until August 24 to comment on the draft rule and can do so by sending an email to the HHSC IG Rules Comments Inbox at IG_Rules_Comments_Inbox@hhs.texas.gov.