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

2. Project Schedule/Scope of Work and General Requirements
2.1 Project Schedule
Milestones and due dates for deliverables will be determined later by HHSC.
2.2 Project Scope
RAC shall perform all recovery audit(s) and fraud-related audit services and all services
reasonably related to such recovery audit(s) and fraud-related audit services. RAC shall provide
all the recovery audit(s) and fraud-related audit services in compliance with all requirements of
this RFP and the contract. RAC shall perform the recovery audit(s) and fraud-related audit
services consistent with HHSC’s guidelines, directives, and rules, which may be passed and as
amended in the future. RAC shall comply with such current guidelines and rules and any such
amended guidelines and rules throughout the term of the contract. All required recovery audit(s)
and fraud-related audit services must be provided at a highly competitive fee level, i.e., the fee
quoted should be the best value to HHSC when all evaluation criteria are considered. HHSC
reserves the right, in its sole discretion, to enter into preliminary and/or final negotiations with
more than one of the top respondents.
Contractor will:
2.3 Contractor Responsibilities
2.3.1. General Requirements
a. Illustrate a good understanding of the Texas Medicaid program and propose a Medicaid
improper payment recovery audit solution that will identify improper payments resulting
in the recovery of payments, or refund of payments, of inappropriate billings by
providers, including both Fee For Service (FFS) and managed care claims. Although the
Texas Medicaid program does not intend to include managed care claims for review
under the RAC Program initially, the RAC should take into consideration in its proposal
that managed care claims may be included in the RAC Program after the Centers for
Medicare & Medicaid Services (CMS) provides further guidance and best practices
regarding managed care.
b. Illustrate a good understanding of the Texas Medicaid program related to program
integrity and propose audit workplans and solutions for fraud, waste and abuse
identification, including managed care organizations (MCOs), and pharmacy benefit
managers (PBMs).
c. Be proficient in performing improper payment and fraud-related risk assessments,
detecting improper payments and fraud, waste or abuse, utilizing efficient methods for
improper payment and fraud, waste or abuse detection, handling large volumes of data,
understanding control systems and weaknesses, audit report writing, and project
administration and management.
d. Hold entrance conference with HHSC prior to start of any audit activities.
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