The office of inspector general must place payment holds on provider reimbursement claims in specified situations, must do so immediately and without prior notice, and must set guidelines for payment holds. It also has authority to decline, limit, or remove a hold for listed good-cause reasons, and it may not impose a hold for certain medically necessary services if prior authorization was obtained and there is no evidence of material misrepresentation.
Sec. 544.0301. IMPOSITION OF PAYMENT HOLD. (a) As authorized by state and federal law and except as provided by Subsections (d) and (e), the office of inspector general shall impose, as a serious enforcement tool to mitigate ongoing financial risk to this state, a payment hold on claims for reimbursement submitted by a provider only: (1) to compel production of records; (2) when requested by this state's Medicaid fraud control unit; or (3) on the determination that a credible allegation of fraud exists, subject to Sections 544.0104(b) and 544.0105(b), as applicable. (b) The office of inspector general shall impose a payment hold under this section without prior notice, and the payment hold takes effect immediately. (c) The office of inspector general shall, in consultation with this state's Medicaid fraud control unit, establish guidelines regarding the imposition of payment holds authorized under this section. (d) On the determination that a credible allegation of fraud exists and in accordance with 42 C.F.R. Sections 455.23(e) and (f), the office of inspector general may find that good cause exists to not impose a payment hold, to not continue a payment hold, to impose a payment hold only in part, or to convert a payment hold imposed in whole to one imposed only in part if: (1) law enforcement officials specifically requested that a payment hold not be imposed because a payment hold would compromise or jeopardize an investigation; (2) available remedies implemented by this state other than a payment hold would more effectively or quickly protect Medicaid funds; (3) the office of inspector general determines, based on the submission of written evidence by the provider who is the subject of the payment hold, that the payment hold should be removed; (4) Medicaid recipients' access to items or services would be jeopardized by a full or partial payment hold because the provider who is the subject of the payment hold: (A) is the sole community physician or the sole source of essential specialized services in a community; or (B) serves a large number of Medicaid recipients within a designated medically underserved area; (5) the attorney general declines to certify that a matter continues to be under investigation; or (6) the office of inspector general determines that a full or partial payment hold is not in the best interests of Medicaid. (e) Unless the office of inspector general has evidence that a provider materially misrepresented documentation relating to medically necessary services, the office of inspector general may not impose a payment hold on claims for reimbursement the provider submits for those services if the provider obtained prior authorization from the commission or a commission contractor. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.