Tex. HHSC Medicaid Hospice Provider Manual § 1300

Revision 06-2; Effective December 12, 2006

Section 1909 of the Social Security Act explicitly states the penalties applied to providers that commit certain fraudulent acts in the administration of Medicaid programs. HHSC urges providers to become familiar with this section of the act and abide by it. Providers involved in fraudulent practices are subject to review, fraud referral, and/or administrative sanctions that could result in withholding of vendor payments, termination or suspension of Medicaid contracts. The Attorney General's office investigates suspected Medicaid provider fraud that could result in a felony conviction. The following are examples of activities that may result in administrative sanctions against providers such as vendor hold, termination, or suspension from the Medicaid program:

presenting any false or fraudulent claim for services or merchandise;

submitting false information to obtain greater compensation than the provider is legally entitled;

submitting false information to meet Medicaid contracting requirements;

failing to disclose and/or make available upon demand to HHSC or its authorized agent records of services provided to Medicaid recipients and of payments made for those services;

failing to comply with the terms of the Medicaid provider contract;

rebating or accepting a fee or portion of a fee or charge for a Medicaid recipient referral;

being excluded from Medicare because of fraudulent or abusive practices;

charging individuals for Medicaid-allowable services over and above that paid by HHSC, except when specifically allowed by HHSC;

failing to correct deficiencies in provider operations after receiving written notice of the deficiencies from HHSC;

being convicted of a criminal offense relating to performance of a provider agreement with the state;

failing to repay or make arrangements to repay identified overpayments;

failing to abide by applicable civil rights statutes.

Report knowledge of suspected Medicaid fraud or abuse of provider services to:

Medicaid Program Integrity

Health and Human Services Commission

P.O. Box 13247

Austin, TX 78711-3247

800-436-6184

Arrangements between NFs and hospice providers are vulnerable to fraud and abuse practices. National trends include health care fraud and potential violations of the Medicare anti-kickback statute, both of which can influence the referral of NF residents for hospice services. Report suspected fraud involving NFs and hospices to:

Centers for Medicare and Medicaid Services

Regional Office of Inspector General

U.S. Department of Health and Human Services

1301 Young Street, Room 833

Dallas, TX 75202

214-767-8406

or

Department of Health and Human Services

Office of Inspector General

P.O. Box 23489, L'Enfant Plaza Station

Washington D.C., 20026-3489

800-447-8477