Fwa Case Study

The Provider Manual summarizes the definitions of FWA set forth in 1 TAC §371.1 as follows: Waste is defined as activities “involving payment or the attempt to obtain payment…where there was no intent to deceive or misrepresent, but…poor or inefficient methods results in unnecessary costs” to Medicaid. Abuse is defined as activities “that unjustly enrich a person…but where the intent to deceive is not present,” or “an attempt…to unjustly obtain a benefit payment.” Finally, the Provider Manual defines fraud as “an intentional misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit….”

If so, this investigation must include

a review of all materials related to previous investigations, the outcome of the previous investigations, and a determination of whether the new allegations are the same or related.
The sample must consist of a minimum of 50 recipients or 15% of the provider’s claims related to the suspected FWA (and if the sample is based upon 15% of the claims, it must include claims for at least 50 recipients). (Id.)
The separate issue of failing to provide records must also be reported, as discussed in Section VI, below.
On its website page addressing Medicaid managed care complaints, appeals and provider resolution issues, HHSC states, “Medicaid managed care providers must exhaust the complaints or grievance process with their managed care medical plan before filing a complaint with HHSC. If after completing this process, the provider believes they did not receive full due process from the managed care plan, they may file a…complaint or inquiry to [HHSC Medicaid/CHIP Health Plan Management]….” See hhs.texas.gov/services/health/Medicaid-and-chip-about-medicaid/Medicaid-and-chip-contact-us.
The three year period is consistent with the look-back period in the Affordable Care Act. (42 C.F.R. § 455.508(f)). The Provider Manual provides that Community First intends to comply with ACA. (Provider Manual, p. 135)