(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...

RAC shall implement, maintain and operate a web-based application approved by HHSC
that allows providers to customize addresses, send inquiries related to the audit, etc., and
allows HHSC and providers to check the status of medical records requests and case
review (i.e.: outstanding, received, review underway, review complete, case closed);
HHSC is requesting a respondent to recommend a web-based application to satisfy the
requirement. HHSC will review the recommendation and then, if approved by HHSC, the
successful respondent will be required to implement, maintain and operate the web-based
application. If HHSC does not approve of the recommended web-based application
proposed by a respondent, HHSC may request a respondent to provide additional
alternatives to the original web-based application until an acceptable application is
approved. The successful respondent will be required to implement, maintain and operate
an HHSC approved web-based application.
RAC shall not seek legal representation or pursue any judicial action surrounding the
improper payment recovery audit(s) and/or other fraud-related audit processes performed;
RAC may solicit HHSC’s opinion about whether a detected overpayment should be
recovered or underpayment repaid if determination of the improper payment remains
unclear after normal audit process activities have been exhausted. HHSC shall use its
discretion when determining whether a payment should be recovered or repaid;
RAC shall supply HHSC with an extract (to be defined during the Governance Process) of
the RAC’s data that corresponds to a list of identified improper payments or any fraudulent
activity upon request;
RAC shall supply HHSC with a monthly report, in a format approved by HHSC that
includes: the overpaid or underpaid amounts detected to date; the reason the RAC
determined an improper payment occurred; and any other information related to the
improper payment as requested by HHSC. The report shall contain the status as of the
close of business of the last day of each calendar month, and is due to HHSC no later
than the 7 th day of the month. The first monthly report is due one month after the first audit
begins, or upon a mutually agreed upon date.
RAC shall supply HHSC with a draft provider audit report for each respective audit
completed, in a format approved by HHSC. The draft report is due to HHSC within 30 days
after each provider audit concludes. The draft report(s) shall identify all improper payments
or fraudulent activities, and the reasons thereof. The RAC will be required to provide final
reports incorporating HHSC’s comments. Provider comments will be incorporated into the
report conclusions, at HHSC’s sole discretion.
RAC shall identify improper payments only during the HHSC-defined audit period, which
may not exceed a maximum three-year claims look-back period from the date the claim
was filed, unless a different time period is authorized by the State; for fraud-related
investigations, the look-back period is five years from date of service, unless a different
time period is authorized by the State.
RAC shall retain all documentation relating to each respective audit during the contract
period and for 3 years following the date the final payment is made to the RAC, or the date
upon which all questions involving the improper payments or fraudulent activities validity
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