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

HHSC invites qualified RACs to submit proposals in accordance with this RFP. HHSC plans to
contract with one or more successful RAC(s) to perform the recovery audit and fraud-related audit
services. The contract activities are anticipated to begin on or about September 1, 2012, or as
soon thereafter as practical.
The requested improper payment audit services include the detection, validation, and tracking and
reporting of improper payments made by Texas Medicaid to providers resulting from: (i) duplicate
payments; (ii) pricing errors; (iii) payments for services not provided; (iv) non-covered services
(including services that are not reasonable and necessary under Section 1862(a) (1) (A) of the
Social Security Act); or (v) any other errors resulting in improper payments. The RAC will be
required to determine the causes of the improper payments, suggest recommendations to remedy
those causes, and issue formal reports to HHSC documenting the results of each audit performed.
Additionally, the other requested audit services include recovery projects or other initiatives related
to fraud investigations and program integrity efforts as determined by HHSC.
It is expected that one award will be made from this RFP; however, HHSC reserves the right, in its
sole discretion, to make more than one contract award as a result of the issuance of this RFP. All
questions in this RFP must be answered with information that is responsive to the request or item.
The RAC, as an independent contractor, shall provide improper payment and other fraud-related
audit services under the contract at its facilities and with its own personnel. The initial term of the
contract is expected to be about September 1, 2012, through August 31, 2015. HHSC shall have
the option, in its sole discretion, to extend the contract for up to three additional one (1) year
periods, one (1) year at a time.
1.5. Mission Objectives
The Texas Health and Human Services Commission’s (HHSC) mission in this Request for
Proposals (RFP) is to award a contract to a qualified RAC to conduct payment recovery audit
services for improper 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 based on a contingency fee, as well as a fixed fee for other audit services related to fraud
investigations and program integrity efforts as determined by the HHSC.
The RAC should be knowledgeable of Expansion of the Recovery Audit Contractor Program as
outlined in Section 6411 of the ACA, which amends Section 1902(a)(42), Social Security Act (42
U.S.C. Section 1396a(a)(42) by adding 42 C.F.R. Sections 455.500-455.518, as well as
applicable guidance established by the Centers for Medicare & Medicaid Services (CMS). To
gain additional knowledge, potential bidders may research: RAC Status Document (see
www.cms.hhs.gov/rac).
The RAC will identify underpayments and overpayments to support Texas implementation of
healthcare reform. Qualified RACs 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; and
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