(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...
(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...
(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...
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1396a(a)(42). HHSC is required to contract with a <strong>RAC</strong> <strong>for</strong> purposes of identifying<br />
underpayments <strong>and</strong> overpayments in the <strong>Texas</strong> Medicaid Program.<br />
HHSC may award the contract to a qualified <strong>RAC</strong> to per<strong>for</strong>m the improper payment recovery<br />
audit(s) <strong>and</strong> other audit services related to fraud investigations requested by this <strong>RFP</strong>. During<br />
the term of this contract, the <strong>RAC</strong>, as an independent contractor, <strong>and</strong> not as an employee of the<br />
state, shall provide the improper payment recovery audit(s) <strong>and</strong> other audit services as more<br />
fully set <strong>for</strong>th below:<br />
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<strong>RAC</strong> shall be proficient in per<strong>for</strong>ming improper payment <strong>and</strong> fraud-related risk<br />
assessments, detecting improper payments <strong>and</strong> fraud, waste or abuse, utilizing efficient<br />
methods <strong>for</strong> improper payment <strong>and</strong> fraud, waste or abuse detection, h<strong>and</strong>ling large<br />
volumes of data, underst<strong>and</strong>ing control systems <strong>and</strong> weaknesses, audit report writing, <strong>and</strong><br />
project administration <strong>and</strong> management;<br />
<strong>RAC</strong> may utilize statistical sampling, regression, digital analysis, data mining, <strong>and</strong> other<br />
risk assessment or error detection techniques to increase the efficiency of the improper<br />
payment detection process, <strong>and</strong> fraud, waste or abuse detection. <strong>RAC</strong> must utilize those<br />
techniques when the <strong>RAC</strong> believes that the outcome maximizes the overpayments that will<br />
be identified;<br />
<strong>RAC</strong> shall identify improper payments made in a population of the State’s payments as<br />
determined by HHSC, or as recommended by the <strong>RAC</strong> <strong>and</strong> approved by HHSC. The<br />
<strong>RAC</strong>’s review shall identify improper payments including, but not limited to: (i) duplicate<br />
payments; (ii) pricing errors; (iii) payments <strong>for</strong> services not provided; (iv) payments <strong>for</strong> noncovered<br />
services (including services that are not reasonable <strong>and</strong> necessary under Section<br />
1862(a)(1)(A) of the Social Security Act); or (v) any other errors resulting in improper<br />
payments. Additionally, claims reviewed or under review by the <strong>Texas</strong> <strong>Health</strong> & Human<br />
Services Commission’s Office of Inspector General (OIG), or associated with an audit<br />
already underway (i.e. PERM audit, Federal OIG audit or review, CMS audit or review,<br />
CMS contractor audit or review), or other Federal <strong>and</strong> State audits or reviews shall be<br />
excluded from the population of State payments subject to <strong>RAC</strong> audits. HHSC may<br />
exclude other types of payments from <strong>RAC</strong> audits at their sole discretion. The audit<br />
population will only include eligible payments from fiscal years as determined by HHSC,<br />
which may not exceed a three-year maximum claims look-back period from the date the<br />
claim was filed, unless a different time period is authorized by the State.<br />
<strong>RAC</strong> shall work cooperatively with entities, including, but not limited to those identified<br />
above. The <strong>RAC</strong> shall also coordinate, in consultation with HHSC, with the<br />
a<strong>for</strong>ementioned entities or other entities, as directed by HHSC. Such coordination ef<strong>for</strong>ts<br />
are intended to ensure an efficient <strong>and</strong> effective process between the review of the<br />
Medicaid providers <strong>and</strong> the actual audit <strong>and</strong> identification of improper payments, <strong>and</strong><br />
fraud, waste or abuse. The coordination includes keeping HHSC <strong>and</strong> all stakeholders<br />
apprised of potential areas of vulnerability <strong>and</strong> avoiding duplication of ef<strong>for</strong>ts. Further<br />
clarification regarding the process <strong>for</strong> communication <strong>and</strong> coordination between the HHSC<br />
<strong>and</strong> the <strong>RAC</strong>, <strong>and</strong> all outside entities will be defined further in subsequent operating<br />
procedures.<br />
<strong>RAC</strong>, when per<strong>for</strong>ming auditing tasks under a contingency fee payment arrangement,<br />
shall follow applicable professional st<strong>and</strong>ards during the course of each audit to ensure<br />
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