The executive commissioner must adopt audit rules for providers in the medical assistance program, and those rules must include notice, timing, interview, report, appeal, and review procedures.
Sec. 32.070. AUDITS OF PROVIDERS. (a) In this section, "provider" means an individual, firm, partnership, corporation, agency, association, institution, or other entity that is or was approved by the commission to provide medical assistance under contract or provider agreement with the commission. (b) The executive commissioner shall adopt rules governing the audit of providers in the medical assistance program. (c) The rules must: (1) provide that the agency conducting the audit must notify the provider, and the provider's corporate headquarters, if the provider is a pharmacy that is incorporated, of the impending audit not later than the seventh day before the date the field audit portion of the audit begins; (2) limit the period covered by an audit to three years; (3) provide that the agency conducting the audit must accommodate the provider's schedule to the greatest extent possible when scheduling the field audit portion of the audit; (4) require the agency conducting the audit to conduct an entrance interview before beginning the field audit portion of the audit; (5) provide that each provider must be audited under the same standards and parameters as other providers of the same type; (6) provide that the audit must be conducted in accordance with generally accepted government auditing standards issued by the Comptroller General of the United States or other appropriate standards; (7) require the agency conducting the audit to conduct an exit interview at the close of the field audit portion of the audit with the provider to review the agency's initial findings; (8) provide that, at the exit interview, the agency conducting the audit shall: (A) allow the provider to: (i) respond to questions by the agency; (ii) comment, if the provider desires, on the initial findings of the agency; and (iii) correct a questioned cost by providing additional supporting documentation that meets the auditing standards required by Subdivision (6) if there is no indication that the error or omission that resulted in the questioned cost demonstrates intent to commit fraud; and (B) provide to the provider a preliminary audit report and a copy of any document used to support a proposed adjustment to the provider's cost report; (9) permit the provider to produce documentation to address any exception found during an audit not later than the 10th day after the date the field audit portion of the audit is completed; (10) provide that the agency conducting the audit shall deliver a draft audit report to the provider not later than the 60th day after the date the field audit portion of the audit is completed; (11) permit the provider to submit to the agency conducting the audit a written management response to the draft audit report or to appeal the findings in the draft audit report not later than the 30th day after the date the draft audit report is delivered to the provider; (12) provide that the agency conducting the audit shall deliver the final audit report to the provider not later than the 180th day after the date the field audit portion of the audit is completed or the date on which a final decision is issued on an appeal made under Subdivision (13), whichever is later; and (13) establish an ad hoc review panel, composed of providers practicing or doing business in this state appointed by the executive commissioner, to administer an informal process through which: (A) a provider may obtain an early review of an audit report or an unfavorable audit finding without the need to obtain legal counsel; and (B) a recommendation to revise or dismiss an unfavorable audit finding that is found to be unsubstantiated may be made by the review panel to the agency, provided that the recommendation is not binding on the agency. (d) This section does not apply to a computerized audit conducted using the Medicaid Fraud Detection System or an audit or investigation of fraud and abuse conducted by the Medicaid fraud control unit of the office of the attorney general, the office of the state auditor, the office of the inspector general, or the Office of Inspector General in the United States Department of Health and Human Services. Added by Acts 2005, 79th Leg., Ch. 811 (S.B. 630), Sec. 1, eff. September 1, 2005. Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.143, eff. April 2, 2015.