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

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1396a(a)(42). HHSC is required to contract with a RAC for purposes of identifying underpayments and overpayments in the Texas Medicaid Program. HHSC may award the contract to a qualified RAC to perform the improper payment recovery audit(s) and other audit services related to fraud investigations requested by this RFP. During the term of this contract, the RAC, as an independent contractor, and not as an employee of the state, shall provide the improper payment recovery audit(s) and other audit services as more fully set forth below: RAC shall be proficient in performing improper payment and fraud-related risk assessments, detecting improper payments and fraud, waste or abuse, utilizing efficient methods for improper payment and fraud, waste or abuse detection, handling large volumes of data, understanding control systems and weaknesses, audit report writing, and project administration and management; RAC may utilize statistical sampling, regression, digital analysis, data mining, and other risk assessment or error detection techniques to increase the efficiency of the improper payment detection process, and fraud, waste or abuse detection. RAC must utilize those techniques when the RAC believes that the outcome maximizes the overpayments that will be identified; RAC shall identify improper payments made in a population of the State’s payments as determined by HHSC, or as recommended by the RAC and approved by HHSC. The RAC’s review shall identify improper payments including, but not limited to: (i) duplicate payments; (ii) pricing errors; (iii) payments for services not provided; (iv) payments for noncovered 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. Additionally, claims reviewed or under review by the Texas Health & Human Services Commission’s Office of Inspector General (OIG), or associated with an audit already underway (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 shall be excluded from the population of State payments subject to RAC audits. HHSC may exclude other types of payments from RAC audits at their sole discretion. The audit population will only include eligible payments from fiscal years as determined by HHSC, which may not exceed a three-year maximum claims look-back period from the date the claim was filed, unless a different time period is authorized by the State. RAC shall work cooperatively with entities, including, but not limited to those identified above. The RAC shall also coordinate, in consultation with HHSC, with the aforementioned entities or other entities, as directed by HHSC. Such coordination efforts are intended to ensure an efficient and effective process between the review of the Medicaid providers and the actual audit and identification of improper payments, and fraud, waste or abuse. The coordination includes keeping HHSC and all stakeholders apprised of potential areas of vulnerability and avoiding duplication of efforts. Further clarification regarding the process for communication and coordination between the HHSC and the RAC, and all outside entities will be defined further in subsequent operating procedures. RAC, when performing auditing tasks under a contingency fee payment arrangement, shall follow applicable professional standards during the course of each audit to ensure 8
due diligence in its efforts to identify funds legitimately owed to the State or the Medicaid provider in the case of improper payments. When performing auditing tasks under a noncontingency fee payment arrangement, the RAC shall follow generally accepted government auditing standards during the course of each audit. RAC shall work directly with HHSC, as needed, when performing the recovery audit(s) and fraud-related audit services. RAC must minimize the administrative burden on HHSC to the extent practicable; RAC shall furnish all material, labor, equipment, and supplies necessary to perform the recovery audit(s) and fraud-related audit services required. RAC shall not remove any original state agency records from the site of their location at the agencies. When travel is necessary to conduct the recovery audit(s) and fraud-related audit services, RAC shall be responsible for all travel expenses incurred; HHSC shall not supply postage, long distance phone service, or email services to RAC for the recovery audit(s) and/or fraud-related audit services. HHSC shall not pay for any other related incidental expenses or costs associated with the review process; RAC shall remain mindful of the sensitive business relationship that exists between the State and its Medicaid providers. RAC must obtain HHSC approval prior to communicating, either in writing or orally, with any Medicaid providers regarding any RAC audit activities; once HHSC has approved a RAC audit(s), the RAC will contact and correspond with providers in a manner so as to complete the scope of work within the agreed upon timeframes for the audit(s). The identification of improper payments shall be the sole responsibility of the RAC as described in RFP section 2.3. RAC shall work with the Medicaid providers to identify improper payments and amounts owed to HHSC 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). RAC shall not accept any recovery payments directly or indirectly from any providers; The methods the RAC uses to identify the improper payments, or identify fraud, waste or abuse shall be in accordance with all related laws, statutes, rules and any contract terms; RAC shall identify any improper payments made, or fraud, waste or abuse by communicating this information to HHSC prior to notifying providers on the identified improper payments or fraudulent activities (HHS OIG will provide additional guidance on a case-by-case basis, as needed for fraud, waste or abuse guidelines). RAC must show HHSC proof of each improper payment or fraudulent activities with sufficient detailed supporting information as determined by HHSC so that the agency does not have to review the respective provider’s payment history in order to determine its agreement with the improper payment or fraudulent activities finding. At a minimum, the proof must include the cause of the improper payment or fraudulent activities and the amount of the improper payment. RAC must provide any information HHSC requests for proof of the improper payment, or fraudulent activities when the information is available to the RAC. The RAC may refer to HHS Circular C-027 for general guidelines for reporting fraud, waste, or abuse by Medicaid providers. HHSC will refer any fraudulent activities identified by the RAC to the HHS OIG; 9
Page 1 and 2: Tom Suehs, Executive Commissioner R
Page 3 and 4: 4.3 Statewide Annual HUB Utilizatio
Page 5 and 6: define the requirements of Section
Page 7: Coordination with HHSC in obtaining
Page 11 and 12: are resolved, whichever happens las
Page 13 and 14: 1.8.2 Conflicts of Interest A confl
Page 15 and 16: 1.13 Protest Procedures Texas Admin
Page 17 and 18: e. Establish a Governance process w
Page 19 and 20: . Notify providers in writing of po
Page 21 and 22: timeline will include reasonable an
Page 23 and 24: . Provide monthly status reports to
Page 25 and 26: 2.6 Location of Services The RAC wi
Page 27 and 28: Respondents must notify HHSC of any
Page 29 and 30: identify trade secret or confidenti
Page 31 and 32: 3.15.1 Part I - Business Proposal T
Page 33 and 34: work as a prime contractor or subco
Page 35 and 36: 3.15.4.6 Section 6 - Proposed Appro
Page 37 and 38: Respondents must base their Cost Pr
Page 39 and 40: 3.15.30 Proposed Compensation Table
Page 41 and 42: 4. Historically Underutilized Busin
Page 43 and 44: 4.6.1 Identify Subcontracting Areas
Page 45 and 46: 4.6.7 Written Justification of the
Page 47 and 48: 5. Proposal Evaluation HHSC will us
Page 49 and 50: after HHSC receives payment from th
Page 51 and 52: the overpayments recovered or the u
Page 53: (7) Statistician (8) Other Professi

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

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