1. (a) The Office of Inspector General (the Inspector General) is a division within the Health and Human Services Commission (the Commission). The Inspector General is responsible for the investigation of fraud and abuse in the provision of health and human services (HHS) in Medicaid and other HHS programs. As part of its authority, the Inspector General may impose sanctions upon a finding by the Inspector General of fraud and abuse in Medicaid. The Inspector General is also responsible for the enforcement of state law relating to the provision of health and human services in Medicaid and other HHS programs. As a result, the Inspector General may also investigate a suspected regulatory violation in a non-Medicaid, HHS program and, upon a finding of a violation, may direct the HHS program to take appropriate enforcement action to the extent of the HHS program's regulatory authority. The Inspector General administers program integrity and enforces program violations to the extent of applicable law governing Medicaid and the provision of other health and human services. This includes pursuing Medicaid and other health and human services fraud, abuse, overpayment, and waste. To accomplish the objectives of this chapter, the Inspector General implements review processes to distinguish payment discrepancies that can be corrected through routine payment adjustments from those suspected to result from program violations requiring investigation and possible administrative enforcement or judicial action.

2. (b) The Inspector General establishes objectives and priorities for the office that emphasize:

   1. (1) coordinating investigative efforts to aggressively recover funds;
   2. (2) allocating resources to cases that have the strongest supportive evidence and the greatest potential for recovery of money; and
   3. (3) maximizing opportunities for referral of cases to the Office of the Attorney General.

3. (c) In addition to performing functions and duties otherwise provided by law, the Inspector General may:

   1. (1) assess administrative penalties otherwise authorized by law on behalf of the Commission;
   2. (2) request that the Attorney General obtain an injunction to prevent a person from disposing of an asset identified by the Inspector General as potentially subject to recovery by the Inspector General due to the person's fraud or abuse;
   3. (3) provide for coordination between the Inspector General and special investigative units formed by managed care organizations or entities with which managed care organizations contract to identify and investigate fraudulent claims and other types of program abuse by recipients and providers, and approve the plan of the special investigative units to prevent and reduce fraud and abuse;
   4. (4) audit the use and effectiveness of state or federal funds, including contract and grant funds, administered by a person or state agency receiving the funds from a health and human services agency;
   5. (5) conduct investigations relating to the funds described in paragraph (4) of this subsection; and
   6. (6) recommend policies promoting economical and efficient administration of the funds described in paragraph (4) of this subsection and the prevention and detection of fraud and abuse in the administration of those funds.
4. (d) The Inspector General may require employees of health and human services agencies to provide assistance to the Inspector General in connection with its duties relating to the review, investigation, and audit of fraud, abuse, and overpayment in the provision of health and human services.
5. (e) The Inspector General is entitled to access to any information maintained by a health and human services agency, including internal records, relevant to the functions of the office. This chapter sets forth the types of activities performed by the Inspector General to ensure program integrity.
6. (f) The Commission may obtain any information or technology necessary to enable the Inspector General to meet its responsibilities as mandated by state statute.

Source Note:The provisions of this §371.11 adopted to be effective January 9, 2005, 29 TexReg 12128.