Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012 Page: 8,010
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evidence or written argument regarding whether payment hold is war-
ranted and any related issues to be considered during the informal re-
view. Submission of documentary evidence or written argument, how-
ever, is no guarantee that OIG will not ultimately maintain imposition
of the hold.
(3) A person may request an expedited administrative ap-
peal hearing after receipt of a notice of payment hold in accordance
with 371.1615(d) of this subchapter (relating to Appeals). OIG must
receive the written request for an appeal no later than the tenth calendar
day after the date the person receives the notice.
(4) If both an informal review and an administrative hear-
ing are requested, the administrative hearing and all pertinent discov-
ery, prehearing conferences, and all other issues and activities regard-
ing the administrative hearing will be abated until all informal review
discussions have concluded without settlement or resolution of the is-
sues.
(e) Scope and effect of payment hold.
(1) Once a person is placed on payment hold, payment of
Medicaid or other HHS program claims for specific procedures or ser-
vices and any other payments to the person from an HHS agency will
be limited or denied.
(2) After a payment hold is terminated for any reason, OIG
may retain the funds accumulated during the payment hold to offset
any overpayment, criminal restitution, penalty or other assessment, or
agreed-upon amount that may result from ongoing investigation of the
person, including any payment amount accepted by the prosecuting
authorities made in lieu of a prosecution to reimburse the Medicaid
or other HHS program.
(3) The payment hold may be terminated or partially lifted
upon the following events:
(A) OIG or a prosecuting authority determines that
there is insufficient evidence of fraud by the person if the hold is based
upon an allegation of fraud;
(B) legal proceedings related to the person's alleged
fraud are completed if the hold is based upon an allegation of fraud;
(C) the Medicaid Fraud Control Unit asks OIG to lift
the hold if the hold is based upon the Unit's request;
(D) the duration of the hold expires if the hold was im-
posed for a specific, limited time;
(E) OIG and the person have agreed to lift the hold in
whole or in part during an informal resolution;
(F) OIG determines in its sole discretion that there is
insufficient evidentiary or legal basis for maintaining the hold;
(G) OIG determines in its sole discretion that it is in the
best interests of the Medicaid program to lift the hold;
(H) OIG determines that a payment hold would ad-
versely affect clients' access to care;
(I) an administrative law judge or judge of any court of
competent jurisdiction orders OIG to lift the hold in whole or in part;
or
(J) all proceedings against the provider, including any
appeals and judicial review, have been exhausted and all overpayments
and other reimbursements are satisfied.
371.1715. Damages and Penalties.
(a) Application. OIG may assess administrative damages,
penalties, or both against any person if it determines that the personcommitted an act for which a person is subject to administrative
actions or sanctions, including the following:
(1) presents or causes to be presented to OIG or its fiscal
agent, a claim that contains a statement or representation the person
knows or should know to be false;
(2) commits an act of self-dealing in violation of 371.1669
of this subchapter (relating to Self-Dealing);
(3) commits a managed care violation prohibited by
371.1663 of this subchapter (relating to Managed Care);
(4) fails to maintain adequate documentation to support a
claim for payment in accordance with the requirements specified by
rule or policy of Medicaid or Texas Medicaid Managed Care program
policy; or
(5) engages in any other conduct that OIG has defined as a
program violation.
(b) Exceptions.
(1) Unless the provider submitted information to OIG for
use in preparing a voucher that the provider knew or should have known
was false or failed to correct information that the provider knew or
should have known was false when provided an opportunity to do so,
this section does not apply to a claim based on the voucher if OIG
calculated and printed the amount of the claim on the voucher and then
submitted the voucher to the provider for the provider's signature.
(2) Subsection (a)(2) of this section does not prohibit a per-
son from engaging in generally accepted business practices, including:
(A) conducting a marketing campaign;
(B) providing token items of minimal value that adver-
tise the person's trade name;
(C) providing complimentary refreshments at an infor-
mational meeting promoting the person's goods or services;
(D) providing a value-added service if the person is an
MCO; or
(E) other conduct specifically authorized by law, in-
cluding conduct authorized by federal safe harbor regulations (42 CFR
1001.952).
(c) Notice.
(1) Notice of preliminary report. If after an examination
of the facts OIG determines by prima facie evidence that a person
commits a violation that subjects the person to assessment of damages
or penalties, OIG may issue a preliminary report stating the facts on
which it based its conclusion, its proposal that administrative damages
or penalty under this section be imposed, and stating the amount of the
proposed damages or penalty. OIG will issue notice of the preliminary
report to the person subject to the assessment.
(2) Content of the notice of preliminary report. The notice
of preliminary report will include:
(A) a brief summary of the facts forming the basis for
the assessment;
(B) a statement of the amount of the proposed damages
or penalty; and
(C) a statement of the person's right to an informal re-
view of the alleged violation, the amount of the damages or penalty, or
both the alleged violation and the amount of the damages or penalty.37 TexReg 8010 October 5, 2012 Texas Register
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Texas. Secretary of State. Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012, periodical, October 5, 2012; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth288982/m1/195/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.