Maximizing Reimbursement Under Texas Prompt Pay Laws

Transcription

1 In This Issue Maximizing Reimbursement Under Texas Prompt Pay Laws Impact of the Sarbanes-Oxley Act of 2002 on Privately-Held, For-Profit Healthcare Companies Who Can Bill Medicare For Diagnostic Tests? Texas Expands Medicaid Fraud Laws Did you know... Did you know that you can find all the papers and presentations from past JW seminars on our Web site? Go to A Health Industry Law Newsletter WINTER 2004 Maximizing Reimbursement Under Texas Prompt Pay Laws Many physicians and providers were relieved when the Texas legislature recently enacted the new prompt pay provisions of Senate Bill 418. Several of the gaps in the previous prompt pay legislation have been closed, and physicians and providers now look forward to KAREN PYATT faster reimbursement on claims and the potential of steeper monetary penalties if an HMO or an preferred provider carrier underpays or fails to timely pay claims. A common misconception, however, is that Senate Bill 418 completely supercedes the prompt pay provisions of House Bill 610 MARY EMMA KARAM and its accompanying rules. In actuality, HMO and preferred provider carriers are now governed by two sets of rules, both of which must be understood by physicians and providers in order to receive the maximum reimbursement allowable under provider contracts and Texas law. In order to obtain maximum reimbursement under provider contracts, physicians and providers must know when Texas prompt pay laws apply, which prompt pay Electronically submitted claims are considered to be clean claims if they are compliant with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) standards for electronic submission of claims. law applies to a particular claim, when payment on a claim is due and what penalties to expect for underpayment or late payment of claims. The Texas Department of Insurance maintains the position that prompt pay laws will only apply when a physician or provider has provided services to a person covered under an HMO or an insured PPO plan, but will not apply when health care coverage provided by self-funded ERISA plans 1, workers compensation coverage, Medicare, Medicaid, TriCare and indemnity policies. Once it is determined that a particular claim for payment is covered by prompt pay laws, physicians and providers must identify which of the two laws applies to the claim. Applying Senate Bill 418 The prompt pay provisions of Senate Bill 418 apply to the adjudication of claims covered by contracts between providers and HMOs or insurers that were entered into or renewed on or after August 16, To avoid application of the new prompt pay laws, some insurers renewed contracts effective August 15, Other provider contracts are continuous and do not contain a clause renewing the contract after a specified period of time. The prompt pay provisions of Senate Bill 418 do not apply to these contracts. Senate Bill 418 and its accompanying rules generally do not apply to non-contracted providers except in limited circumstances. 2 Once it is determined that Senate Bill 418 applies to a particular claim, a physician or provider can identify the date on which payment should be received and the penalties for late payment of a claim. Senate Bill 418 requires HMOs and preferred provider carriers to pay or deny electronically submitted clean claims by the 30th day after receipt of the claim and non-electronically submitted clean claims by the 45th day after receipt. 3 If it is determined that a claim will be audited, the audited portion of the claim must be paid in full pending the outcome of the audit or it will be considered an underpayment. The key to payment during this time period is the submission of a clean claim. The prompt payment provisions of House Bill 610 and Senate Bill 418 only apply to clean claims. Senate Bill 418 has redefined clean claim to make it easier on physicians and providers to comply with the clean claim requirement. Electronically submitted claims are considered to be clean claims if they are compliant with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) standards for electronic submission of claims. Claims that are not submitted electronically must contain data elements specified by Senate Bill 418, and if applicable, any amount paid by a primary plan or other valid coverage. HMOs or preferred provider carriers may make a one-time request to a physician or provider for additional information to determine if a particular claim is payable. This request must be made by the 30th day following receipt of the claim and will toll the applicable 30 or 45 day payment period until the information requested is received or a response is received from the physician or provider stating that it does not possess the requested information. The HMO or preferred provider carrier must then pay or deny the claim by the later of the 15th day after receipt of an appropriate response from a physician or provider, or the end of the applicable payment period. (cont. on page 2) Health Brief is published periodically by the law firm of Jackson Walker L.L.P. to inform readers of recent developments in health care law and related areas. It is not intended nor should it be used as a substitute for legal advice or opinion which can be rendered only when related to specific fact situations. TRADITION AND INNOVATION SINCE 1887 More information regarding Jackson Walker may be found on the Internet at Jackson Walker L.L.P.

2 Maximizing Reimbursement Under Texas Prompt Pay Laws (cont.) Senate Bill 418 provides a graduated penalty for claims that are not timely paid. Physicians and providers are entitled to the following penalties for late payment of claims in addition to the contracted rates: If a claim is paid between the 1st and 45th day following the applicable payment period, the physician or provider is entitled to receive a penalty equal to the lesser of 50% of the difference between the contracted rate and billed charges, or $100, If a claim is paid between the 46th and 90th day following the applicable payment period, the physician or provider is entitled to receive a penalty equal to the lesser of 100% of the difference between the contracted rate and billed charges, or $200,000. If the claim is paid on or after the 91st day following the applicable payment period, the physician or provider is entitled to receive a penalty equal to 100% of the difference between the contracted rate and billed charges plus 18% annual interest on the penalty amount. If an HMO or preferred provider carrier underpays a claim, the following penalties apply: If the balance of a claim is paid between the 1st and 45th day following the applicable payment period, the physician or provider is entitled to receive a penalty equal to the lesser of 50% of the underpaid amount, or $100,000. If the balance of a claim is paid between the 46th and 90th day following the applicable payment period, the physician or provider is entitled to receive a penalty equal to the lesser of 100% of the underpaid amount, or $200,000. If the balance of a claim is paid on or after the 91st day following the applicable payment period, the physician or provider is entitled to receive a penalty equal to 100% of the underpaid amount plus 18% annual interest on the penalty amount. Applying House Bill 610 Contracted providers that have Evergreen contracts or contracts that were entered into or renewed prior to August 16, 2003, must look to House Bill 610 for guidance on claims submission and payment. Like Senate Bill 418, the prompt pay provisions of House Bill 610 apply only to the submission of clean claims. Under House Bill 610, however, the definition of clean claim is broader and allows HMOs and preferred provider carriers to make additional requirements in order for a claim to be considered clean. A physician or provider submits a clean claim under House Bill 610 by providing the required data elements specified by the rule along with any attachments or additional elements requested by the HMO or preferred provider carrier of which the physician or provider has been properly notified. HMOs and preferred provider carriers have much more latitude to make their own determinations as to what constitutes a clean claim under House Bill 610 and many physicians and providers have been surprised to learn that the prompt pay provisions do not apply to many of their claims because the claims fail to include all of the data elements required by the rule (CMS-1500 field 15, for example) or they do not include the correct attachments or additional data elements required by a particular insurer. Physicians and providers must make sure they are aware of the clean claim requirements for each of their contracts with HMOs or preferred provider carriers in order to qualify for prompt payment of claims under House Bill 610. Once a clean claim has been submitted, House Bill 610 requires the claim to be paid or denied within 45 days after the HMO or preferred provider carrier receives the claim. If a claim is audited, 85% of the contracted rate of the audited portion of the claim must be paid within the statutory payment period. If a clean claim is not paid or denied within the statutory time period, HMOs and preferred provider carriers are liable for 100% of the billed charges 5 or the contracted penalty rate. Though most physicians and providers prefer the prompt pay provisions of Senate Bill 418, reimbursement can be maximized under either law by understanding and complying with the nuances of each. Awareness of what is owed, when it should be paid and what penalties are available will help physicians and providers collect every dollar owed under the prompt pay laws. If you have any further questions concerning Texas prompt pay laws, please feel free to call Karen Pyatt at (214) or Mary Emma Karam at (214) A recent case in the United States District Court in the Northern District of Texas held that ERISA did not preempt a prompt pay claim brought against Blue Cross Blue Shield of Arkansas, the payor of a fully insured ERISA plan. See Baylor University Medical Center v. Arkansas Blue Cross Blue Shield, Civil Action No. 3:03-CV-2084-G (N.D. Tex. Jan. 9, 2004). 2.The Verification and Effect of Filing a Clean Claim provisions of Senate Bill 418 apply to non-contracted physicians providing services on or after August 16, 2003: a) on referral from an HMO, PPO or preferred provider because the services were not reasonably available in-network; or b) that are emergency care services. 3.Senate Bill 418 and House Bill 610 have 21-day adjudication periods for pharmacy claims. 4. Billed Charges under Senate Bill 418 are the charges for medical or health care services included on a claim submitted by a physician or provider. 5. Billed charges under House Bill 610 are the charges made by a physician or provider who renders or furnishes services, treatments, or supplies provided the charge is not in excess of the general level of charges made by other physicians or providers who render or furnish the same or similar services, treatments, or supplies to persons in the same geographical area and whose illness or injury is comparable in nature or severity. In the event of a case rate agreed to between the physician or provider and the HMO or preferred provider carrier, billed charges shall be considered the higher of the case rate or billed charges. Impact of the Sarbanes-Oxley Act of 2002 on Privately-Held, For-Profit Healthcare Companies JAMES S. RYAN, III The impact on public companies of the Sarbanes- Oxley Act of 2002 (the SOA ) has been widely publicized. The provisions of the SOA have been particularly noted in the for-profit healthcare community because, in connection with the criminal investigation of HealthSouth Corporation and several of its officers, the federal government for the first time brought criminal charges based on the financial statement certification provisions of Section 906 of the SOA. Most provisions of the SOA specifically apply to publicly held corporations, although SOA criminal provisions concerning obstruction of justice through document destruction and retaliation apply directly to privately held and nonprofit concerns. Certain provisions of the SOA that specifically apply to publicly held companies, particularly those related to public company financial statement certifications and certifications regarding internal controls and procedures, should affect the conduct of many privately held for-profit healthcare concerns, particularly those anticipating a liquidity event through a sale of the company or an initial public offering. Maintenance of effective compliance plans goes hand-in-hand with maintenance of the types of internal controls and procedures that will result in development of accurate financial statements. Background Information Regarding Financial Statement Certifications Section 302 Certification Section 302 of SOA is a civil statute that requires that the principal executive officer and principal financial officer of each company required to file periodic reports with the Securities and Exchange Commission (the Commission ) provide a written certification with each quarterly and annual report filed with the Commission. Each Section 302 certification must state that: (1) the officer has reviewed the report; (cont. on page 3) 2

3 Impact of the Sarbanes-Oxley Act of 2002 on Privately-Held, For-Profit Healthcare Companies (cont.) (2) based on the officer s knowledge, the report does not contain any untrue statement of a material fact or omit to state a material fact necessary in order to make the statements made, in light of the circumstances in which such statements were made, not misleading; and (3) based on the officer s knowledge, the financial statements, and other financial information included in the report, fairly present in all material respects the financial condition and results of operations of the company as of, and for, the periods presented in the report. Additionally, the signing officers must state in the Section 302 certification that they are responsible for and have established, maintained, and reviewed their company s systems of internal controls in order to ensure the accuracy of the company s reports, as follows: (4) the signing officers (a) are responsible for establishing and maintaining internal controls; (b) have designed such internal controls to ensure that material information relating to the company and its consolidated subsidiaries is made known to such officers by others within those entities, particularly during the period in which the periodic reports are being prepared; (c) have evaluated the effectiveness of the company s internal controls as of a date within 90 days prior to the report; and (d) have presented in the report their conclusions about the effectiveness of their internal controls based on their evaluation as of that date. Finally, under Section 302 of SOA, the signing officers must certify that: (5) the signing officers have disclosed to the company s auditors and the audit committee of the board of directors (a) all significant deficiencies in the design or operation of internal controls which could adversely affect the company s ability to record, process, summarize, and report financial data and have identified for the company s auditors any material weaknesses in internal controls; and (b) any fraud, whether or not material, that involves management or other employees who have a significant role in the company s internal controls; and (6) the signing officers have indicated in the report whether or not there were significant changes in internal controls or in other factors that could significantly affect internal controls subsequent to the date of their evaluation, including any corrective actions with regard to significant deficiencies and material weaknesses. Section 906 Certification Section 906 of SOA is a criminal statute that requires that each periodic report containing financial statements filed by a publicly held company with the Commission be accompanied by a written statement signed by the company s principal executive officer and principal financial officer stating that the periodic report fully complies with the requirements of the Securities Exchange Act of 1934, and that the information contained in the report fairly presents, in all material respects, the financial condition and results of operations of the company. Section 906 of SOA further provides that whoever: (1) certifies any such Section 906 statement knowing that the periodic report accompanying the statement does not comport with all the requirements set forth in Section 906 shall be fined not more than $1,000,000 or imprisoned not more than 10 years, or both; or (2) willfully certifies any such Section 906 statement knowing that the periodic report accompanying the statement does not comport with all the requirements set forth in Section 906 shall be fined not more than $5,000,000, or imprisoned not more than 20 years, or both. Effect of Certifications on Privately Held For-Profit Healthcare Concerns Many privately held for-profit healthcare concerns anticipate a liquidity event either through an initial public offering or through a sale of the company. Those companies considering an initial public offering must establish internal controls and procedures well in advance of the offering that are designed to later enable its principal executive officer and chief financial officer to be in position to make the Section 302 and Section 906 certifications. Additionally, these companies should anticipate (i) increased requirements from their independent public accountants and their directors and officers liability insurance carriers and (ii) intense due diligence by prospective underwriters, all in an effort to ensure that the company is, in fact, ready to become a reporting company in the post-soa environment. Healthcare concerns contemplating an initial public offering must also contemplate other SOA requirements, including requirements related to the composition and structure of the audit committee, as well as prohibitions on loans to executive officers and directors. For-profit concerns that do not intend to go public but may be sold should also maintain solid internal controls and procedures, and would be well advised to obtain an annual financial statement audit. Many logical prospective purchasers will be publicly held, and a publicly held buyer must be in a position to consolidate the financial statements of the business it purchases and establish that the controls and procedures of the purchased entity are sufficient to enable the purchaser s chief executive officer and chief financial officer to make the required certifications for the combined entity. Additionally, if the acquired business is material to the purchaser, stand-alone audited financial statements of the acquired company are likely to be required to be filed by the purchaser under Form 8-K. In connection with potential sales transactions, privately held companies can expect extensive financial due diligence by prospective purchasers, particularly focusing on internal controls and procedures, as well as requirements regarding representations and warranties related to financial statements and internal controls and procedures. Note that even privately held purchasers often will focus on these issues because those companies themselves may ultimately undertake an initial public offering or a sale to a publicly held entity. Continued Importance of Compliance Plans Finally, the SOA requirements lead to the conclusion that maintenance of an effective compliance plan continues to be important for publicly held and privately held healthcare providers. Maintenance of effective compliance plans goes hand-in-hand with maintenance of the types of internal controls and procedures that will result in development of accurate financial statements. Following the passage of the SOA, the American Health Lawyers Association and the Department of Health and Human Services Office of Inspector General produced an excellent paper titled Corporate Responsibility and Corporate Compliance: A Resource for Healthcare Boards of Directors, that addresses compliance programs for public and privately held for-profit healthcare providers, as well as nonprofit healthcare providers in light of SOA. That paper can be found at 3

4 Who Can Bill Medicare For Diagnostic Tests? Hospitals and other non-physician providers constitute over 75% of national healthcare spending. Ultimately, however, hardly a dollar is spent except on the order of the physician treating the patient. Physicians thus control, directly or indirectly, virtually 100% of the healthcare expenditures in the country. Physician groups understand this reality, JED MORRISON and increasingly seek as much as possible to capture or participate in the revenue attributable to nonphysician services furnished to patients. The most common way for physicians to participate in such revenues is to provide ancillary diagnostic and therapeutic services in the group s office, with equipment owned or leased by the group, and services provided by technicians under their employ. These in-office services (commonly lab or x-ray) appropriately are billed by the medical group. Often, however, a medical group wants to expand into more sophisticated services, but doesn t have sufficient patient volume (or sufficient financial resources) to warrant the purchase of expensive equipment and the employment of full-time technicians. These groups often look for affiliations with other diagnostic providers, to enable the group to provide diagnostic services in the office, both for the convenience of the patient as well as for the possible revenue enhancement for the group. This scenario raises substantial issues with both the Stark and anti-kickback statutes. As a starting point, though, this article examines the question of who may bill Medicare for diagnostic services. Mere performance of the test off-site does not preclude the group from billing Medicare as long as it can prove the necessary supervision. Medicare Coverage of Diagnostic Tests The statutory basis for Medicare coverage of imaging services is the coverage of medical and other health services under Medicare Part B. 42 U.S.C. 1395(k)(a)(1). Specifically covered are "diagnostic X-ray tests... and other diagnostic tests." Only diagnostic imaging procedures that are performed by a physician, a group practice of physicians, a portable x-ray supplier, or an independent diagnostic testing facility ( IDTF ) are payable under the Medicare physician fee schedule. 42 C.F.R An important basic rule is that diagnostic tests must be ordered by the physician who is treating the patient and who uses the results of the test in the management of the patient s specific medical problem. Otherwise such tests are considered not reasonable and necessary and are not payable by Medicare. 42 C.F.R (a). Supervision of Diagnostic Tests In addition to being properly ordered by the treating physician, all diagnostic imaging services must be provided under one of three levels of physician supervision: general, direct, or personal. Diagnostic tests that are not furnished under the appropriate level of physician supervision, again, are deemed not reasonable and necessary, and therefore are not covered by Medicare. 42 C.F.R (b). The most basic level of supervision is general. General supervision requires that a procedure be furnished under a physician s overall direction and control, but the physician s presence is not required during the performance of the procedure. The physician is responsible for the overall training and capabilities of the technicians and maintenance of the equipment, but need not be on site. CT s without contrast, for example, typically are subject to general supervision. Direct supervision in a physician office context means that the physician has to be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Direct supervision is the same level of supervision required for incident to billing by Medicare. A CT of the abdomen with contrast requires direct supervision. Finally, personal supervision, which is required for certain more complex procedures, means the physician must be in attendance in the room during the performance of the entire procedure. All diagnostic x-ray and other diagnostic tests furnished to Medicare patients and payable under the physician fee schedule must be furnished under at least a general level of physician supervision. 42 C.F.R (b)(3). In addition, some of those tests also require either direct or personal supervision as defined above. When direct or personal supervision is required, supervision at that level is required throughout the performance of the test. CMS has published a program memorandum listing the precise supervision requirements, by CPT Code, for all relevant diagnostic tests. Purchased Diagnostic Tests What happens if the diagnostic test is not performed at the billing physician s office, or it is not performed by its employees? Although the requirements for ordering and performing diagnostic tests under the Medicare statute and regulations do not specifically require that the tests be performed at the location of the medical group that bills for the tests, nor do they require that the physician who ordered the test be the physician who supervises the test, the prohibition against the markup of diagnostic tests under 42 U.S.C. 1395u(n) contains a requirement that the physician billing or another physician in his practice personally perform or supervise the test. Where that is not the case - - in other words, where the billing physician cannot truthfully certify and document that the test was performed under his or one of his group member s supervision (e.g., when the test is performed off-site) - - that is considered a purchased diagnostic test, and the claim form must indicate the identity and the charge of the supplier who actually performed (and supervised) the test. The charge by the billing physician must not exceed the lower of the Medicare fee schedule, or the amount paid to the supplier who actually performed the test. In other words, the billing physician may not mark up the test. Moreover, if the claim form does not properly identify that supplier, no payment may be made by Medicare for the technical component of that test, and no co-payment or deductible may be collected from the beneficiary for such test. Conclusion A medical group that wishes to provide diagnostic tests and bill for them under the Medicare Physician Fee Schedule must be able to document that its own doctors or staff actually performed the diagnostic tests under the appropriate level of physician supervision. Mere performance of the test off-site does not preclude the group from billing Medicare as long as it can prove the necessary supervision. Conversely, though, simply providing the test onsite does not ensure payment if a doctor in the group did not supervise the test, or if it was not performed by one of the employees or contractors of the group. Failure to properly bill Medicare for diagnostic tests can result in denied payments, recoupments, and potentially even liability for damages and penalties under the False Claims Act if the improper billing was done intentionally, or with reckless disregard to the accuracy of the claims. 4

5 Texas Expands Medicaid Fraud Laws The 78th Texas Legislature recently adopted significant revisions to existing Texas Medicaid Fraud statutes in House Bill Health care providers who participate in the Medicaid program should be aware of the following new Medicaid Fraud provisions: CARLA COX Prepayment and Postpayment Reviews Amendments to of the Human Resources Code provide for prepayment and postpayment reviews of a claim for Medicaid reimbursement to determine whether the claim involves fraud or abuse. Payment may be withheld for 5 working days for prepayment review without notice. Postpayment holds may be placed on payment of future claims if the Department of Human Services has reliable evidence of fraud or willful misrepresentation regarding a Medicaid claim. The provider must be given notice of a postpayment hold not later than 5th working day after imposition of the hold. An expedited administrative hearing is available on timely written request by provider. The hearing must be requested within 10 calendar days of receipt of the notice of vendor hold. The Health and Human Services Commission ( HHSC ) is to adopt rules to provide for informal resolution of postpayment holds. The provider has 10 days from date of notice to seek informal resolution. The request for informal resolution does not extend the deadline for requesting an expedited hearing. Therefore, an informal review and expedited hearing must be requested at the same time. The violation of a fraud or antikickback statute is a state jail felony. The Attorney General is, for the first time, given the authority to prosecute criminal violations with the consent of local prosecutor. Surety Bonds HHSC may require a Medicaid provider to post a surety bond in a reasonable amount if HHSC identifies a pattern of suspected fraud or abuse involving criminal conduct relating to Medicaid services and there is a need for protection against future abuse. Fraud and Anti-kickback Actions that are prohibited under the newly-adopted State fraud and anti-kickback statutes are: Knowingly presenting a false claim; Engaging in conduct that violates Section of the Occupations Code, i.e., knowingly offering to pay or agreeing to accept, directly or indirectly, overtly or covertly any remuneration in cash or in kind to or from another for securing or soliciting a patient or patronage for or from a person licensed, certified, or registered by a state health care regulatory agency; Soliciting or receiving any remuneration, in cash or in kind, for referring an individual to a Medicaid provider of goods or services; Soliciting or receiving payments in cash or in kind to induce a person to purchase, lease or order items that are paid for by the Medicaid program; Paying or offering to pay any remuneration to induce a person to refer an individual to another person for Medicaid services; Paying or offering to pay any remuneration to induce a person to purchase, lease or order items that are paid for by the Medicaid program; Providing an inducement to a individual, recipient, provider or employee of a provider for the purpose of influencing a decision regarding selection of a provider of Medicaid services or goods paid for by the Medicaid program. Generally accepted business practices, as determined by HHSC rule, do not violate the anti-kickback prohibitions. Such accepted practices include: Conducting a marketing campaign; Providing token items of minimal value that advertise a trade name; Providing complimentary refreshments at an informational promotional meeting; Conduct authorized by the federal safe harbor provisions. Civil Penalties for Fraud, Abuse and Anti-kickback Violations Civil penalties for Medicaid fraud and anti-kickback violations are provided in the amount paid as a result of the violation plus interest and an administrative penalty equal to two times the amount paid. In addition, penalties for a violation that results in an injury to an elderly or disabled person will be enhanced by an additional $5,000-15,000 per violation and a 10 year exclusion from the Medicaid program. Penalties that result from a violation that does not result in an injury to an elderly or disabled person will be enhanced by up to $10,000 for each violation and a three year exclusion from the Medicaid program. Exclusion may be waived based on criteria to be set out by rule. Criminal Penalties for Fraud, Abuse and Anti-kickback Violations The violation of a fraud or anti-kickback statute is a state jail felony. The Attorney General is, for the first time, given the authority to prosecute criminal violations with the consent of local prosecutor. The Attorney General has authority to prosecute the following crimes with the consent of the local prosecutor: Penal Code Theft Penal Code Misappropriation of Fiduciary Property Penal Code Securing Execution of a Document by Deception Penal Code Tampering with a Government Record Third Party Billing Vendors If a Medicaid provider uses a third party billing company to process and submit Medicaid bills, these new requirements will apply: The third party billing vendor must have a contract with the department authorizing that activity. The third party billing vendor must provide the Attorney General with access to and copies of any records maintained by the vendor. HHSC will send notice of a claim filed by a third party vendor to the Medicaid provider. The provider is required to review the claim for accuracy. The provider must notify the department of any errors in the billing. Investigations of fraud or abuse by HHSC Office of the Inspector General The OIG must conduct an integrity review of each complaint of Medicaid fraud or abuse to determine whether there is sufficient basis to conduct full investigation. The integrity review must begin (cont. on page 6) 5

6 Texas Expands Medicaid Fraud Laws (cont.) Austin 100 Congress Avenue, Suite 1100 Austin, Texas (512) fax (512) Dallas 901 Main Street, Suite 6000 (214) fax (214) Fort Worth 301 Commerce Street, Suite 2400 Fort Worth, Texas (817) fax (817) Houston 1401 McKinney Street, Suite 1900 Houston, Texas (713) fax (713) Richardson 2435 N. Central Expressway, Suite 600 Richardson, Texas (972) fax (972) days after receipt of the complaint and must be completed within 90 days after the review is begun. If an integrity review indicates fraud or abuse involving criminal conduct by a provider, the OIG must refer to the AG within 30 days. If the integrity review indicates that a recipient has defrauded the Medicaid program, the OIG may conduct a full investigation. HHSC is required to refer cases to the Attorney General s Medicaid Fraud Control Unit whenever the Commission learns or has reason to suspect that a provider s records are being withheld, concealed, destroyed, fabricated, or in any way falsified. HHSC is authorized to put a facility on vendor hold without prior notice to compel the production of records to either HHSC or the Attorney General s Medicaid Fraud Control Unit (MFCU). Unless vendor hold is requested by the AG s MFCU, the provider is entitled to an expedited hearing on the basis for the vendor hold. Forfeiture of Contraband In a criminal prosecution, the Attorney General may seize as contraband any property that is used or intended to be used in the commission of a violation of any felony that involves the Medicaid program. The forfeited property is to be transferred to HHSC for the recovery of amounts wrongfully obtained by the owner of the property or penalties and damages to which HHSC is otherwise entitled. San Angelo 301 West Beauregard, Suite 200 San Angelo, Texas (915) fax (915) San Antonio 112 East Pecan Street, Suite 2100 San Antonio, Texas (210) fax (210) TRADITION AND INNOVATION SINCE Main Street Suite 6000 Dallas, Texas