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

6. Detailed findings organized by type of improper payment or fraudulent activity,
including amount of improper payment or fraudulent activity, complete description
of the cause of the improper payment or fraudulent activity, and a
recommendation to remedy the cause.
c. RAC must recommend a web-based application 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.
d. Recommend system changes to prevent future improper payments.
e. Recommend solutions/concepts to improve the Texas Medicaid program based on
findings from audits related to fraud investigations.
2.3.6. Data Sharing and Security
a. After consultation with HHSC, identify and provide a complete list/description of required
data fields necessary from HHSC for review of claims associated with the audit.
b. Propose a solution that will have minimal impact on the current operations of the MMIS;
include a high-level diagram of expected data flow.
c. Provide secure transmission of data exchange, and provide a description to the HHSC of
the process that will be used for secure data exchange.
d. Follow all federal and state rules and regulations as they apply to the disclosure of
protected health information (PHI) obtained from HHSC that is necessary for the
performance of the recovery audit and fraud-related audit services. This applies to a
person acting under this contract, and each employee or agent of the person.
2.3.7. Recoupment and Appeals Process
a. Identify claims with improper payments and provide the details to HHSC for recoupment
of overpayments or repayment of underpayments.
b. Invoice and receive payment for only those funds recovered by HHSC for overpayments,
or for underpayments actually paid to providers by the state, during the life of the
contract; any funds recovered by HHSC for overpayments or underpayments actually
paid to providers by the state after each agreed upon audit completion date will be
excluded from the contingency and/or fixed fee calculation and payment. Each audit
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