Texas 5913 Form in PDF

Detailed Guide for Writing Texas 5913

Filling out the Texas 5913 form might seem daunting, but it's an important step in ensuring the integrity of services provided to individuals in need. This form is used to report suspected fraudulent activities by providers to the Texas Department of Aging and Disability Services. By following a step-by-step guide, the process can be made clear and manageable. Here's how to accurately complete the form:

1. Begin with the section labeled "For Consumer Rights and Services (CRS) Use Only" at the top of the form. Since this section is intended for internal use, you can skip this and move directly to the section regarding the submission of the referral.
2. Under "Contact Information for DADS Staff Submitting Referral," enter your name, title or position, and the DADS Area or State Office Region No. If your role doesn't fit the predefined categories, select "Other" and specify your role.
3. Provide the DADS Office Street Address, including the Mail Code, City, State, and ZIP Code. Then, complete the area code and telephone number along with any extension, and finish this section with your email address.
4. Next, address the "Contact Information for Witness With Information About Suspected Fraudulent Activity" section. If applicable, fill in the name, contact information, and physical address of anyone who can substantiate the suspicion of fraud. Mark "N/A" if there are no witnesses.
5. Answer if a Law Enforcement Agency was notified about the suspected fraudulent activity by selecting "Yes" or "No" and provide the details of the notification, including the name of the agency, date notified, and contact information of the individual spoken to.
6. Similarly, indicate whether another entity, like an Insurance Company or Bank, was notified by selecting "Yes" or "No" and provide the relevant details if applicable.
7. Under "Provider Information," fill in the details of the suspected fraudulent provider, including the legal entity name, any DBA (Doing Business As), Texas ID No. (TIN), contract number, license number, and other required identifiers. Also, provide both the physical and business mailing addresses.
8. Specify the "Type of Provider" by selecting the appropriate category from the list provided on the form.
9. Indicate the "Type of Suspected Fraudulent Activity" by choosing from billing irregularities, falsification/alteration of records, trust fund irregularities, or another specified fraudulent activity.
10. Enter the date or date range during which the suspected fraudulent activity occurred.
11. Choose the "Type of Review" that led to the suspicion of fraudulent activity, such as an administrative review, investigation, site certification review, etc.
12. Complete the section regarding the "Information Review Period," "Total Sample Size," and "Total Individuals Served." Also, indicate if the suspected fraudulent activity was noted outside the sample or review period.
13. Fill in details about any corrective action or recoupment requested as a result of the review, including the amount due to DADS as a result of this review and how much of this amount is suspected to be fraudulent.
14. In the "Other Information" section, note whether the provider has received technical assistance on billing in the past two years.
15. For HCSSA, Adult Day Care, and Assisted Living licensed providers, enter the number of level B citations if applicable, using the links provided in the form for reference.
16. Lastly, provide any detailed descriptions of the suspected fraudulent activity and any additional pertinent information before submitting the form to the email addresses provided for DADS staff or OIG/OAG investigators.

Upon completion, ensure all information provided is accurate and truthful to the best of your knowledge. Filing this form is a crucial step in maintaining the integrity and quality of care provided to individuals, making reporting any suspected fraudulent activity an important responsibility.

When completing the Texas Department of Aging and Disability Services Form 5913, individuals often make mistakes that can delay the processing of a suspected provider fraud referral. Identifying these common errors can help ensure the form is filled out accurately and efficiently.

1. Incorrect or Incomplete Contact Information: One of the most frequent mistakes is providing incorrect or incomplete contact information for either the DADS staff submitting the referral or for the witness with information about the suspected fraudulent activity. It's crucial to double-check all phone numbers, email addresses, and physical addresses to ensure they are current and accurate.

2. Failing to Notify the Proper Authorities: Another oversight is neglecting to notify the law enforcement or other relevant entities, such as insurance companies or banks, about the suspected fraud. It's important to indicate on the form whether law enforcement or another entity has been notified, including the name of the agency or entity, the date they were notified, and contact information for the individual notified.

3. Omitting Details About Suspected Fraudulent Activity: Sometimes, individuals fail to provide a detailed description of the suspected fraudulent activity. This section is vital for giving the Texas Health and Human Services Commission (HHSC) Office of Inspector General (OIG) the information needed to initiate an investigation. Including specific dates or date ranges, types of suspected fraudulent activities, and any other relevant details can significantly aid in the investigative process.

4. Misunderstanding the Types of Providers and Activities: A common confusion arises from misunderstanding the types of providers and the specific activities that may be considered fraudulent. Form 5913 lists various types of providers and activities. Ensuring that the correct type of provider and specific suspected fraudulent activity are clearly identified prevents delays and misunderstandings during the review of the referral.

Attending closely to these details can greatly improve the accuracy and efficiency of processing Form 5913, thereby facilitating a smoother investigation into the suspected provider fraud.

When dealing with suspected provider fraud in Texas, it's crucial to have a comprehensive approach. The Texas Department of Aging and Disability Services (DADS) Form 5913 is a critical tool in this effort, allowing for the reporting of suspected fraud to the appropriate authorities. However, it's often just the start of a detailed process that requires multiple documents and forms for a thorough investigation and subsequent actions. Understanding these additional documents can help streamline the process and ensure that all necessary steps are followed.

• Affidavit of Fraudulent Activity: This document acts as a sworn statement detailing the specifics of the suspected fraudulent activity. It supports the information provided in Form 5913 by offering a detailed narrative or account from witnesses or those who discovered the fraud. This legal statement is often used to substantiate claims during investigations.
• Provider Audit Notification Letter: Following the filing of Form 5913, this letter notifies the provider in question that an audit of their records and practices will be conducted. It outlines the scope, legal basis, and objectives of the audit and instructs the provider on how to prepare and what to expect. It serves as a formal initiation of the investigatory process.
• Request for Documentation: Supplements the audit notification by specifying the documents that the provider must submit for review. This could include financial records, patient records, billing statements, and any other documentation relevant to the investigation. It plays a key role in gathering evidence and assessing the validity of the suspected fraudulent activities.
• Suspension of Payment Letter: If preliminary findings suggest that fraud is likely, payments to the provider may be suspended to prevent further loss of funds. This letter informs the provider of the suspension, including the legal and policy basis for the decision, and outlines the process for appealing the suspension. It's a critical step in mitigating potential damages while the investigation is ongoing.

Together, these documents form a comprehensive toolkit for addressing suspected provider fraud in Texas, accompanying the initial use of the Texas DADS Form 5913. Each serves a specific purpose in the process, from providing detailed initial accounts to initiating audits, gathering further evidence, and taking preventive actions while investigations proceed. It's important for all parties involved to understand not only the significance of Form 5913 but also the role of these accompanying documents in ensuring a thorough and fair process.

The Texas 5913 form is closely related to the Federal OIG (Office of Inspector General) Suspected Fraud Reporting Form. Both forms serve the important function of providing a structured method for reporting suspicions of fraud within healthcare or provider services. The Texas 5913 form specifically addresses provider fraud within the Texas Department of Aging and Disability Services, while the Federal OIG form targets a broader spectrum of healthcare fraud across various federal health programs. Despite these differences in scope, each form collects detailed information about the alleged fraudulent activity, including provider details, nature of the suspected fraud, and any witnesses or evidence.

Another comparable document is the CMS (Centers for Medicare & Medicaid Services) 10123-NOMNC (Notice of Medicare Non-Coverage). While the 10123-NOMNC is primarily aimed at notifying patients about the end of covered services, it shares commonalities with the Texas 5913 form in its procedural nature and its connection to regulatory compliance within healthcare settings. Both documents are integral to ensuring that services are provided ethically and legally, with the 10123-NOMNC focusing on patient rights and the Texas 5913 form concentrating on the prevention and reporting of fraudulent practices.

The IRS Form 3949-A, used to report suspected tax fraud, bears similarities to the Texas 5913 form in its objective to report unethical or illegal conduct. While Form 3949-A deals with tax evasion or fraud against the IRS, the Texas 5913 form tackles healthcare provider fraud against state services. Each form is crucial in its respective field for initiating investigations and interventions against fraudulent activities. They both require the reporting party to provide specific information about the individual or entity suspected of fraud, including names, addresses, and a detailed description of the alleged misconduct.

Lastly, the Texas Health and Human Services Commission's (HHSC) Inspector General Complaint Form parallels the Texas 5913 form in its dedication to upholding integrity within healthcare and human services. This form allows individuals to report a variety of concerns, including but not limited to fraud, waste, and abuse in state-administered health and human services programs. Both forms play a pivotal role in protecting resources and ensuring services are delivered appropriately and lawfully, though the HHSC's form has a broader application across different types of complaints beyond fraud.

When completing the Texas 5913 form, it is crucial to adhere to specific guidelines to ensure the accuracy and integrity of the submission. Here are five practices to follow and to avoid for a seamless process.

Do:

1. Verify all provider information, including legal entity name, Texas ID No. (TIN), and physical address, to ensure accuracy.
2. Detail the suspected fraudulent activity clearly, specifying the type of activity and providing a comprehensive timeline of events.
3. Include contact information for any witnesses or individuals with information about the suspected fraud, ensuring it's complete and correct.
4. Notify the appropriate law enforcement agency and other entities, such as insurance companies or banks, if applicable, and document these notifications on the form.
5. Provide a detailed description of the suspected fraudulent activity in the designated section, including any relevant dates or date ranges.

Don't:

1. Leave sections blank that are applicable to the situation. If a section does not apply, mark it as N/A (Not Applicable) instead of leaving it empty.
2. Guess or approximate information. If certain details are unknown, obtain the correct information before submitting the form.
3. Ignore the instructions for specific sections such as those for HCSSA, Adult Day Care, and Assisted Living licensed providers regarding the entry of citation numbers.
4. Forget to review the form for accuracy and completeness before sending it to the Texas Department of Aging and Disability Services (DADS).
5. Omit the date of submission and the signature (if required), as these elements are crucial for the form's validity.

Understanding the intricacies of the Texas Form 5913, associated with the Department of Aging and Disability Services (DADS), reveals several misconceptions that can complicate its use and interpretation. This overview aims to clarify these misconceptions, promoting better comprehension and utilization of the form.

• Misconception 1: Form 5913 Is Only About Reporting Fraud Involving Elderly Care.

  While it's true that the Texas Department of Aging and Disability Services focuses on services for the elderly and disabled, Form 5913 is not limited to those areas alone. It covers suspected fraudulent activities across a range of provider types and services designated on the form, which extends beyond just elderly care facilities to include various healthcare and service providers.

• Misconception 2: Anyone Can File a Report Using Form 5913.

  The form is primarily designed for use by DADS staff or those closely associated with the oversight and administration of service providers. It's not intended for public submission. While the form captures vital information about potential fraud, concerned individuals outside of this scope are encouraged to contact DADS or appropriate authorities through different channels.

• Misconception 3: Form 5913 Reports Are Primarily Concerned With Financial Irregularities.

  Although financial irregularities, such as billing fraud or trust fund issues, are significant, Form 5913 encompasses a broader spectrum of fraudulent activities. This includes falsification of records, licensing issues, and other violations that could affect the quality and integrity of care provided.

• Misconception 4: Completion of Form 5913 Automatically Results in Law Enforcement Investigation.

  Filing this form initiates an internal review process within the Department and its associated entities. While law enforcement agencies may be notified in certain situations, not all submissions will warrant or lead to an external investigation. The form serves as a referral tool within the system to address suspected fraud.

• Misconception 5: The Form 5913 Is a Public Document.

  Due to the sensitive nature of the information it contains, Form 5913 is not a public document. Its circulation is restricted to relevant officials within the Department of Aging and Disability Services and other authorized entities. The confidentiality protocols help protect the integrity of the investigative process and the privacy of all parties involved.

Correcting these misconceptions aims to enhance the understanding and management of suspected provider fraud within the Texas system of care, ensuring that efforts to detect and prevent fraud are as effective as possible.

Understanding the Texas 5913 form is essential for accurately reporting suspected provider fraud within the Texas Department of Aging and Disability Services (DADS). Here are key takeaways to guide individuals in completing and using this form effectively:

• The form is specifically designed for reporting suspected fraudulent activities by providers who offer services to the aging and disabled populations in Texas.
• Contact information for both the individual submitting the referral and a witness, if available, must be provided to facilitate follow-ups on the reported issue.
• It's important to indicate whether law enforcement or other entities (e.g., insurance companies, banks, subcontractors) have been notified about the suspected fraud prior to completing this form.
• The provider information section requires detailed identification, including the legal entity name, doing business as (d.b.a.) name, if applicable, and various identification numbers such as the Texas ID No. (TIN) and Provider Identifier No. (NPI/API).
• Specifying the type of provider and the type of suspected fraudulent activity is critical to direct the form to the appropriate department for investigation.
• Details about the date or date range of the suspected fraudulent activity, as well as the type of review conducted (if any), should be clearly mentioned to provide context to the investigation team.
• It's necessary to mention if any corrective action or recoupment was requested as a result of a review, including the amount suspected to be fraudulently claimed, which helps in assessing the financial impact of the alleged fraud.
• For Home and Community Support Services Agencies (HCSSA), Adult Day Care, and Assisted Living licensed providers, specific links for entering the number of level B citations are provided, underscoring the importance of regulatory compliance history in the investigation process.
• The form includes sections for regulatory services and investigators to fill in after the submission, indicating that the process involves multiple levels of review and investigation.
• Concerns regarding the suspension of the provider's payments and the potential impact on access to care for displaced individuals are addressed, highlighting the balance between fraud prevention and uninterrupted care provision.

Completing and submitting the Texas 5913 form requires careful attention to detail and an understanding of the legal and regulatory framework governing provider services to the aging and disabled communities in Texas. Following these key takeaways will ensure that the information provided is thorough and facilitates a smooth investigative process.