5210  What is Provider Fraud?

The Department of Aging and Disability Services (DADS) endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, when there is an indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, it must be established that:

• intentional misstatement or concealment by the provider created a false impression; or
• DADS paid the provider based on a false impression when the payment would not have been made if the truth had been known.

Examples of provider fraud include:

• billing for services that were not provided;
• filing false claims;
• continuing inappropriate billing after provider education visits; and
• using improper billing practices.

5220  What is Abuse?

To determine the existence of abuse, it must be established that:

• provider practices are inconsistent with sound fiscal, business or medical practices; and
• inconsistent practices result in unnecessary cost to the program, or reimbursement for services that do not follow waiver service criteria or that fail to meet professionally recognized standards of health care or standards required by contract, statute, regulations or interpretations of a statute or regulation sent to the provider.

Examples of provider abuse include:

• providing services that are not medically necessary;
• billing for services provided by inappropriate persons;
• practicing without a proper license or obtaining a license under false pretenses; and
• violating the contract or provider agreement.

5230  Civil Penalty

Cases of fraud or abuse may also be referred to the Health and Human Services Commission (HHSC) for civil penalties under the federal Civil Monetary Law of the Social Security Act. Under this provision, a provider (individual and corporate) may be assessed a fine of up to $2,000 and double damages for each line item identified as fraudulent or abusive billing. HHSC may also require a provider that has been assessed civil monetary penalties to be barred from participation in the Medicare or Medicaid program, or both.

5240  Reporting Fraud and Abuse

Department of Aging and Disability Services (DADS) staff are required to report provider fraud and abuse through established agency procedures. The reporting process is different for DADS contracted providers and non-contracted entities. Refer to Section 5260, Development of the Provider Fraud Referral Packet, for procedures for reporting fraud and abuse by providers contracted with DADS.

For entities not contracted with DADS, reports of fraud and abuse may be completed by calling the:

• DADS Consumer Rights and Services hotline at 1-800-458-9858; and
• Health and Human Services Commission (HHSC) Office of Inspector General (OIG) hotline at 1-800-436-6184
.

Referrals of fraud and abuse may also be submitted by completing the Waste, Abuse and Fraud Referral Form at the HHSC OIG online referral website at https://oig.hhsc.state.tx.us/.

Individuals who are not DADS staff and who know of suspected fraud or abuse of assistance benefits, including eligibility and provider services, are urged to use these reporting options.

DADS case managers must follow procedures in Section 5300, Consumer Fraud Detection and Referral, for making consumer fraud referrals.

5250  Responding to Allegations of Provider Fraud and Abuse

When an allegation of provider fraud is received, Department of Aging and Disability Services (DADS) staff should follow these procedures.

1. During the first contact, staff receiving the allegation should obtain facts relating to the specific case in as much detail as possible. This includes:
   • who engaged or participated in the alleged fraudulent/abusive conduct;
   • what the suspected violation was;
   • when the conduct occurred (dates or time periods);
   • where the conduct occurred;
   • how the fraudulent/abusive action was performed;
   • the names, addresses and telephone numbers of witnesses and how they can be contacted; and
   • if or when a referral to law enforcement was made.
2. DADS staff should try to obtain the complainant's name, address, home telephone and the telephone number where the complainant can be reached during the day. DADS staff should advise informants who wish to remain anonymous that DADS needs a way to contact them during the investigation.
3. DADS staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

5260  Development of the Provider Fraud Referral Packet

Department of Aging and Disability Services (DADS) case managers must consult with their supervisor for guidance in determining the appropriateness of a provider fraud and abuse referral. If it is decided that a referral is to be submitted for a DADS contracted provider, staff follow procedures found on the Contract Oversight and Support (COS) website at http://dadsview.dads.state.tx.us/contract/fraud/index.html.

The case manager gathers information to complete Form 5913, Suspected Provider Fraud Referral.

The form requires:

• contact information and additional collateral contacts for DADS regional and state office staff;
• names, addresses, and work and home telephone numbers of potential witnesses;
• information relating to law enforcement referrals;
• provider information, including name, address, telephone number, provider type and specialty, business address, contract number, facility ID and owning entity;
• type of alleged fraud (billing, falsification of records, solicitation) and identification of a specific policy, regulation or procedural violation, including specific handbook or manual references;
• physical address of where the alleged fraud or abuse took place; and
• other pertinent documentation relating to the incident.

DADS staff may contact COS to determine if a provider fraud and abuse referral has already been made. Check the COS website for information on how to contact COS staff.

5261  Expedited Referrals for Potential Provider Fraud and Abuse

If Department of Aging and Disability Services (DADS) staff have reason to believe that the conduct of the suspected provider is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the supervisor must first be consulted.

An expedited referral should be made when a delay would:

• probably result in the loss, destruction or altering of valuable evidence;
• probably result in harm to a consumer;
• probably result in significant monetary loss to DADS that would probably not be recoverable; or
• hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the HHSC Office of Inspector General fraud hotline at 1-800-436-6184.

5262  Referral of Potential Provider Fraud

If a Department of Aging and Disability Services (DADS) supervisor determines that criteria for a fraud referral are met, a fraud referral is made. Staff follow procedures found on the Contract Oversight and Support (COS) website at http://dadsview.dads.state.tx.us/contract/fraud/index.html.

DADS staff:

• complete Form 5913, DADS Suspected Provider Fraud Referral;
• call the DADS Consumer Rights and Services (CRS) hotline at 1-800-458-9858; and
• fax the completed form to CRS at 877-438-5827 with "Attention: CRS hotline."

CRS will advise DADS staff of further action to take and will make the referral of provider fraud and abuse to the Health and Human Services Commission (HHSC) Office of Inspector General (OIG).

Only if directed to do so by CRS, DADS staff will submit the Waste, Abuse and Fraud Referral Form information to HHSC OIG through one of the following methods:

• online at the HHSC OIG website at https://oig.hhsc.state.tx.us;
• by mail to:
  Texas Health and Human Services Commission
  Office of Inspector General
  Medicaid Program Integrity, Mail Code 1361
  P.O. Box 85200
  Austin, TX 78708-5200
• via fax to 512-973-3185, Attention: Medicaid Program Integrity Intake; or
• by telephone to the HHSC OIG fraud hotline at 1-800-436-6184.

5270  After Referrals of Potential Provider Fraud, What Then?

The Health and Human Services Commission (HHSC) is responsible for ensuring that all pertinent information is obtained about providers and may subsequently request additional information. Providing requested material to HHSC does not constitute a confidentiality violation. The HHSC Office of Inspector General (OIG) will conduct an analysis and collect data to create a complete picture of the provider utilization patterns related to the alleged incident.

After the case is referred to HHSC OIG, no other action is necessary. Department of Aging and Disability Services (DADS) staff should maintain a professional working relationship with the provider while the fraud referral is being investigated. However, for the duration of the investigation, staff must not discuss the alleged violation with provider staff. This prevents the possibility of interference with the investigation.

Investigation of fraud is the responsibility of the state's OIG and could result in a felony conviction, contract termination, exclusion or suspension from the Texas Medicaid program.

5310  What is Consumer Fraud?

To determine the existence of fraud, it must be established that:

• intentional misstatement or concealment by the consumer or responsible party created a false impression; or
• Department of Aging and Disability Services (DADS) staff determined eligibility or the provider delivered services based on a false impression.

Some examples of consumer fraud include:

• knowingly providing false information regarding an applicant's financial, medical or functional status in order to be determined eligible for assistance;
• withholding or concealing information pertaining to the applicant's financial, medical or functional status that may cause the applicant to be ineligible for services;
• receiving services that the consumer knows to be medically unnecessary;
• knowingly receiving services from individuals who do not have a proper license or who obtained a license under false pretenses; and
• falsifying attendant time sheets.

5320  Responding to Allegations of Consumer Fraud

When potential consumer fraud is discovered, Department of Aging and Disability Services (DADS) staff should follow these procedures:

1. Record all pertinent facts relating to the specific case in detail, including:
   • the name of the consumer;
   • the suspected violation;
   • date and time the conduct occurred;
   • place of the occurrence;
   • the fraudulent action;
   • the names, addresses and telephone numbers of individuals with knowledge of the situation and contact information; and
   • if or when a referral to law enforcement was made.
2. If fraud is alleged by a third-party source, try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. DADS staff should advise informants who wish to remain anonymous that DADS needs a way to contact them during the investigation.
3. Do not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

Home and Community Support Services provider staff should follow the above procedures and report information about suspected consumer fraud by mailing Form 2067, Case Information, to the appropriate case manager by the next work day.

Restitution must not be requested in cases where fraud is being investigated or alleged. Once restitution is requested, the case cannot be referred for fraud.

5330  Development of Consumer Fraud Referral

The case manager must consult with the supervisor for guidance in determining the appropriateness of the fraud referral.

The supervisor may require the case manager to call the Department of Aging and Disability Services (DADS) Consumer Rights and Services hotline at 800-458-9858, to determine if the situation is an appropriate consumer fraud referral for investigation by the Texas Health and Human Services Commission (HHSC) Office of Inspector General (OIG) or if the situation should be handled by other referrals or actions.

If a referral to OIG is appropriate, the case manager gathers the information necessary to complete the Waste, Abuse and Fraud Referral Form, located at the HHSC OIG website at https://oig.hhsc.state.tx.us/.

5340  Expedited Referrals for Potential Consumer Fraud and Abuse

If a Department of Aging and Disability Services (DADS) case manager has reason to believe that the conduct of the suspected consumer or responsible party is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the supervisor must first be consulted. An expedited referral should be made when a delay could:

• result in the loss, destruction or altering of valuable evidence;
• result in harm to a consumer;
• result in significant monetary loss to DADS that would probably not be recoverable; or
• hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the Health and Human Services Commission (HHSC) Office of Inspector General Fraud hotline at 800-436-6184.

5350  Referral of Potential Consumer Fraud

If the supervisor determines that criteria for a fraud referral are met, a fraud referral is made.

Routine referrals of potential consumer fraud should be made to the Health and Human Services Commission (HHSC) Office of Inspector General (OIG) through one of the following methods:

• Submit the Waste, Abuse and Fraud Referral Form online. The HHSC OIG Fraud Referral website is: https://oig.hhsc.state.tx.us/.
• Mail the Waste, Abuse and Fraud Referral Form to:
  Texas Health and Human Services Commission
  Office of Inspector General
  Attention: Fraud Hotline Staff
  General Investigations Division, Mail Code 1362
  P.O. Box 85200
  Austin, TX 78708-5200
• Fax the referral to 512-973-3185, Attention: Fraud Hotline Staff.
• Telephone the referral to the HHSC OIG Fraud hotline at 800-436-6184.

5360  After Referrals of Potential Consumer Fraud, What Then?

The Health and Human Services Commission (HHSC) Office of Inspector General (OIG) is responsible for ensuring that all pertinent information is obtained and may subsequently request additional information. Providing requested material to HHSC OIG does not constitute a confidentiality violation. HHSC OIG staff will conduct an analysis and collect data to create a complete picture of the alleged incident.

After the case is referred to HHSC OIG, no other action is necessary. Department of Aging and Disability Services (DADS) staff and provider staff continue to maintain the case as usual. DADS staff and provider staff should preserve a professional working relationship with the consumer or responsible party while the fraud referral is being investigated. However, for the duration of the investigation, DADS staff and provider staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.