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

1. General Information
1.1. Scope
The Texas Health and Human Services Commission’s (HHSC) mission in this Request for
Proposals (RFP) is to award a qualified firm (hereinafter referred to as Recovery Audit
Contractor (RAC)) to conduct improper payment recovery audit services for payments made by
the State of Texas (State) to its Medicaid-enrolled providers for services provided under the
Medicaid State Plan or a waiver of the Medicaid State Plan, and other audit services related to
fraud investigations as determined by the State.
The State of Texas, by and through the Texas Health and Human Services Commission
(HHSC), seeks to award a contract to a qualified Recovery Audit Contractor firm to conduct
audit services for the purpose of identifying overpayments and underpayments (hereinafter
referred to as “improper payments”) made by the State of Texas to its providers in accordance
with the specifications contained in this Request for Proposals (“RFP”). The selected RAC will
identify improper payments made by the Texas Medicaid Program to its Medicaid-enrolled
providers for provider types as determined by HHSC. Qualified RAC are to present the State
with a proposal for:
Detection of Medicaid improper payments
Validation of Medicaid improper payments
Tracking and reporting of Medicaid improper payments
Coordination with HHSC in obtaining approval of recoupment/repayment of identified
improper payments, to include providing all supporting documentation obtained by the
RAC from Medicaid providers necessary for HHSC to conduct appeals.
Additionally, HHSC seeks to award a contract to a RAC to perform recovery projects or other
initiatives related to fraud investigations and program integrity efforts as assigned by HHSC,
whether identified solely by HHSC, or as recommended by the RAC. The contract(s)
resulting from this RFP will be primarily for RAC services paid on a contingency
fee basis, but the contract will additionally provide for other audit services related
to fraud investigations and program integrity efforts paid on a fixed fee basis.
The Fixed Fees will be based on individual Fixed Fee Rates included in the Contract and
the level of effort to perform a specific audit, audit services related to fraud
investigations or any other service provided by the RAC that would not be appropriate to
utilize a contingency fee to compensate the RAC for those specific services rendered.
The Fixed Fees for these services will be based on the explicit fixed hourly rates
proposed by the respondent and the projected number of hours to be worked on the
specific audit or specific project by the respondent’s staff or the staff of the respondent’s
subcontractor. The fixed fee will be proposed by the Contractor prior to the start
of activities for fraud investigations and other services assigned by HHSC,
subject to negotiation and acceptance by HHSC.
The selected RAC must be capable of producing timely services and deliverables of sufficient
quality to achieve HHSC results.
The scope of this contract is subject to change and may require amending upon release of any
future amendments to the final federal rules (42 CFR §§455.500-455.518) that may further
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