UPDATE: HHSC Proposes to Reduce Monies an MCO Obtains from Fraud Recovery to 50% from 100%

UPDATE: We’ve added below an additional HHSC presentation given to the House Committee on General Investigating & Ethics which gives further details of MCO contract management.

This morning HHSC sent out a notice that it was looking for public comments on several proposed rule changes relating to MCO fraud investigations of providers and fund recoveries.

Draft rules on fraud investigations up for public comment

A cursory look at the draft changes shows that MCOs will no longer have to supply a minimum sample of 50 cases relating to the alleged fraud.  This is being reduced to 30.  The proposed rule change even goes further – “The MCO may confirm the suspicious indicators of fraud, waste, and abuse with a review of fewer recipients or claims, provided that the MCO submits a written justification for the decision to substantiate the waste, abuse, or fraud with fewer recipients or claims.”

Also, the new proposed rule will change the amount of money an MCO can keep from its fraud recovery activities.  Currently, the rule states: “An MCO may retain any money recovered by the MCO.”  If HHSC-OIG collects the money, “The HHSC-OIG will distribute any amounts collected to the MCO, less any costs of investigation and collection proceedings.”

Per the draft rule, MCOs would only receive half of the monies collected with the rest going back to the state.

If anyone wishes to review and comment on these changes, copies of the draft documents can be downloaded from here.  Current rules can be found here.

HHSC executives testifying this morning on Managed Care and contracting

Dr. Courtney N. Phillips, Executive Commissioner; Victoria Ford, Chief Policy Officer and Interim Chief Operating Officer; Stephanie Muth, State Medicaid Director, and Mike Maples, Deputy Executive Commissioner are testifying this morning before the House Committee on Human Services.

They have already issued their presentation which contains the latest information on HHSC contracting woes and steps taken to fix them and further information on HHSC oversight of Medicaid Managed Care.

We provide that document for your review.

Update: Presentation to the House Committee on General Investigating & Ethics


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