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

after HHSC receives payment from the provider. It is the RAC’s responsibility to work with
Medicaid providers to identify the improper payments that are owed by them as a result of the
review conducted by the RAC. (Medicaid providers are required to maintain and provide
requested medical records at no cost when requested by HHSC or a designee of HHSC.) The
RAC will not be paid by HHSC unless HHSC secures payment from the applicable provider and
any appeals are resolved. Any payments made to the RAC that are later refunded by HHSC to
the provider as a result of an overturned appeal will be refunded to HHSC within a reasonable
timeframe as prescribed by HHSC or offset against future payments to the RAC.
The RAC’s compensation for underpayments will be based on the amount of the actual
underpayment amounts paid to providers identified from the improper payment recovery review
process. The RAC will be paid either a contingency fee percentage of the underpayments
actually paid to providers or a fixed fee.
The RAC’s compensation for other audit services related to fraud investigations and program
integrity efforts will be based on fixed fees as assigned by HHSC and mutually agreed upon by
HHSC and the RAC.
6.2 Business Objective
The objective of the Financial Approach is to describe the financial components that will enable
HHSC to achieve the Mission Objectives described in Section 1.5 of the RFP. This approach
will also ensure that all services required of the successful respondent are provided as
efficiently and effectively as possible, and assist HHSC in its responsibility for efficient and
effective administration of federal awards through the application of sound management and
recovery audit practices.
6.3 Financial Payment Structure
The financial payment structure for the Recovery Audit Contractor (RAC) Contract will be based
on contingency fees and/or fixed fees. 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 program integrity efforts, 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 RAC shall submit an invoice by the fifteenth (15th) of each month to HHSC for activity in the
previous calendar month. The invoice shall include:
a. Overpayments Collected by HHSC - Identification of each case for which recovery of an
overpayment has been obtained for the previous calendar month, the amount of the
claim, the amount of the recovery, and the amount of the contingency fee.
Overpayment amounts shall only be on this report if the amount has been
collected from the Medicaid provider (in summary and detail);
b. Underpayments Identified and Paid to the Provider by HHSC - Identification of each
case for which an underpayment was determined in the previous calendar month, the
amount of the underpayment, and the amount of the contingency or fixed fee.
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