It is equally important that the process in place is fair and transparent and does not fail Medicaid providers who are playing by the rules,” she said. Dr. Holcomb testified in support of SB 1803 at a House Human Services Com- mittee in April.
“This legislation creates a framework for rulemaking that will meet the needs of the state for its required oversight of the Medicaid program and providers’ need for transparency and clarity in the resolution of accusations and complaints against them,” he testified. He later told Texas Medicine that
“OIG’s punitive rules make it harder to convince physicians to participate in the Medicaid program.”
TMA gets legislative solution Before HHSC adopted the “program in- tegrity” rules, TMA submitted 35 pages of written comments that outlined the association’s concerns. TMA adamantly opposed the rules, which repealed lan- guage that said not all overpayments to a physician are necessarily fraudulent. Dr. Holcomb asked HHSC officials to re- tain that language and reiterate in the new rules that some overpayments are mistakes, not fraud. However, that didn’t happen.
The agency’s decision to adopt the rules as proposed disheartened Dr. Hol- comb, who says the rules made it “in- creasingly difficult to convince physi- cians to step up to the plate and see new Medicaid patients.” He says the rules allowed “OIG to proceed with payment holds and essentially impound money from doctors without providing appro- priate due process.” At the time, HHSC spokesperson Stephanie Goodman said the agency had to adopt the new rules “to comply with new program integrity requirements in the Affordable Care Act.” Dr. Holcomb said the OIG “made it clear they had no interest in collaborat- ing with TMA on the Medicaid fraud rules. The agency wanted to pursue pay- ment holds against physicians without interference. I’m pleased we made some progress this session in creating an open process for conducting investigations and payment holds.”
August 2013 TEXAS MEDICINE 37
SB 1803 improves due process and transparency within OIG by:
• Promoting transparency and due pro- cess in the investigation and resolu- tion of Medicaid overpayment and payment holds based on a credible allegation of fraud;
• Describing the information that must be included in the notice to physi- cians who are subject to a payment hold or proposed recoupment, in- cluding a description of supporting evidence and a description of the ad- ministrative and judicial due process remedies;
• Providing timelines and procedures for seeking informal resolution of a payment hold or alleged overpay- ment;
• Detailing a physician’s right to appeal a final overpayment determination or payment hold and the applicable timelines for exercising appeal rights;
• Directing OIG to hire a medical direc- tor and dental director to assist with investigations; and
• Directing OIG to post on its website (
https://oig.hhsc.state.tx.us) the poli- cies and procedures used to deter- mine whether to impose a payment hold on a physician.
The bill gives physicians 30 days af-
ter receiving a notice of payment hold or overpayment to request an initial in- formal resolution meeting and 60 days to schedule the meeting. After the ini- tial resolution meeting, physicians may request a second informal meeting. If physicians seek an administrative ap- peal at the State Office of Administrative Hearings (SOAH), both the state and the physicians are responsible for their own expenses for the hearing, including fees charged by SOAH. The bill also provides for an appeal of a final administrative order to Travis County district court.
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