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

. Provide monthly status reports to HHSC detailing all audit activities. The status report
should include, at a minimum, the following data fields:
1. Audit Concept (Description)
2. Number of claims selected for review
3. Number medical documentation requests sent
4. Number medical documentation requests received
5. Number of audits (claims) in progress
6. Percent of audit completed
7. Number of “no findings” results letters sent
8. Number overpayment results letters sent
9. Number of underpayment results letters sent
10. Percent of overpayments and underpayments identified from both the entire
universe of claims provided by claims administrator, and pool of claims
identified for review with potential improper payment
11. Number of dispute resolution requests received
12. Estimated improper payment amount
13. Number of claims adjustment requests submitted
14. Estimated dollar amount of claims adjustments submitted
15. Dollar amount of recoupments completed
16. Provider inquiries received, broken out by reason for provider inquiry
17. Number of referrals to HHSC OIG for suspected fraud, waste, or abuse
18. Any other data fields as identified during course of audit activity and requested
by HHSC
c. After consultation with HHSC, provide and compile required annual reporting regarding
the effectiveness of the Texas Medicaid RAC Program, as defined and requested by
CMS. Elements will include, but are not limited to, general program descriptors and
program metrics to evaluate the effectiveness of the RAC Program.
2.3.10. Coordination
a. Coordinate with HHSC to identify other audits underway to avoid overlap and
duplication of effort with other recovery efforts; this may include, but is not limited to,
coordination with federal and state law enforcement entities, such as the U.S.
Department of Justice, federal OIG, CMS, GAO, State Medicaid Fraud Control Units
(MFCUs), and State Surveillance and Utilization Review Units.
b. Submit claims information selected for potential improper payment review to HHSC
prior to start of review; HHSC will compare, identify and provide to contractor any
claims that should be excluded from the review because it is already under review
under another audit or investigation (i.e. PERM audit, Federal OIG audit or review, CMS
audit or review, CMS contractor audit or review), or other Federal and State audits or
reviews.
c. Coordinate with OIG in scope of work and project plan development for any fraudrelated
audit service activities assigned and agreed upon by HHSC and the RAC.
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