By: J. Davis of Harris H.B. No. 1720
A BILL TO BE ENTITLED
AN ACT
relating to improving health care provider accountability and
efficiency under the child health plan and Medicaid programs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.024161 to read as follows:
Sec. 531.024161. REIMBURSEMENT CLAIMS FOR CERTAIN MEDICAID
OR CHIP SERVICES INVOLVING SUPERVISED PROVIDERS. (a) If a
provider, including a nurse practitioner or physician assistant,
under the Medicaid or child health plan program provides a referral
for or orders health care services for a recipient or enrollee, as
applicable, at the direction or under the supervision of another
provider, and the referral or order is based on the supervised
provider's evaluation of the recipient or enrollee, the names and
associated national provider identifier numbers of the supervised
provider and the supervising provider must be included on any claim
for reimbursement submitted by a provider based on the referral or
order. For purposes of this section, "national provider
identifier" means the national provider identifier required under
Section 1128J(e), Social Security Act (42 U.S.C. Section
1320a-7k(e)).
(b) The executive commissioner shall adopt rules necessary
to implement this section.
SECTION 2. Subchapter C, Chapter 531, Government Code, is
amended by adding Sections 531.1131, 531.1132, and 531.117 to read
as follows:
Sec. 531.1131. FRAUD AND ABUSE RECOVERY BY CERTAIN PERSONS;
RETENTION OF RECOVERED AMOUNTS. (a) If a managed care
organization's special investigative unit under Section
531.113(a)(1) or the entity with which the managed care
organization contracts under Section 531.113(a)(2) discovers fraud
or abuse in the Medicaid program or the child health plan program,
the unit or entity shall:
(1) immediately notify the commission's office of
inspector general;
(2) subject to Subsection (b), begin payment recovery
efforts; and
(3) ensure that any payment recovery efforts in which
the organization engages are in accordance with applicable rules
adopted by the executive commissioner.
(b) If the amount sought to be recovered under Subsection
(a)(2) exceeds $100,000, the managed care organization's special
investigative unit or contracted entity described by Subsection (a)
may not engage in payment recovery efforts if, not later than the
10th business day after the date the unit or entity notified the
commission's office of inspector general under Subsection (a)(1),
the unit or entity receives a notice from the office indicating that
the unit or entity is not authorized to proceed with recovery
efforts.
(c) A managed care organization may retain any money
recovered under Subsection (a)(2) by the organization's special
investigative unit or contracted entity described by Subsection
(a).
(d) A managed care organization shall submit a quarterly
report to the commission's office of inspector general detailing
the amount of money recovered under Subsection (a)(2).
(e) The executive commissioner shall adopt rules necessary
to implement this section, including rules establishing due process
procedures that must be followed by managed care organizations when
engaging in payment recovery efforts as provided by this section.
Sec. 531.1132. ANNUAL REPORT ON CERTAIN FRAUD AND ABUSE
RECOVERIES. Not later than December 1 of each year, the commission
shall prepare and submit a report to the legislature relating to the
amount of money recovered during the preceding 12-month period as a
result of investigations and recovery efforts made under Sections
531.113 and 531.1131 by special investigative units or entities
with which a managed care organization contracts under Section
531.113(a)(2). The report must specify the amount of money retained
by each managed care organization under Section 531.1131(c).
Sec. 531.117. RECOVERY AUDIT CONTRACTORS. To the extent
required under Section 1902(a)(42), Social Security Act (42 U.S.C.
Section 1396a(a)(42)), the commission shall establish a program
under which the commission contracts with one or more recovery
audit contractors for purposes of identifying underpayments and
overpayments under the Medicaid program and recovering the
overpayments.
SECTION 3. Subchapter D, Chapter 62, Health and Safety
Code, is amended by adding Section 62.1561 to read as follows:
Sec. 62.1561. PROHIBITION OF CERTAIN HEALTH CARE PROVIDERS.
The executive commissioner of the commission shall adopt rules for
prohibiting a person from participating in the child health plan
program as a health care provider for a reasonable period, as
determined by the executive commissioner, if the person:
(1) fails to repay overpayments under the program; or
(2) owns, controls, manages, or is otherwise
affiliated with and has financial, managerial, or administrative
influence over a provider who has been suspended or prohibited from
participating in the program.
SECTION 4. Section 32.047, Human Resources Code, is amended
to read as follows:
Sec. 32.047. PROHIBITION OF CERTAIN HEALTH CARE SERVICE
PROVIDERS. (a) A person is permanently prohibited from providing
or arranging to provide health care services under the medical
assistance program if:
(1) the person is convicted of an offense arising from
a fraudulent act under the program; and
(2) the person's fraudulent act results in injury to an
elderly person, as defined by Section 48.002(a)(1) [48.002(1)], a
disabled person, as defined by Section 48.002(a)(8)(A)
[48.002(8)(A)], or a person younger than 18 years of age.
(b) The executive commissioner of the Health and Human
Services Commission shall adopt rules for prohibiting a person from
participating in the medical assistance program as a health care
provider for a reasonable period, as determined by the executive
commissioner, if the person:
(1) fails to repay overpayments under the program; or
(2) owns, controls, manages, or is otherwise
affiliated with and has financial, managerial, or administrative
influence over a provider who has been suspended or prohibited from
participating in the program.
SECTION 5. Subchapter B, Chapter 32, Human Resources Code,
is amended by adding Section 32.068 to read as follows:
Sec. 32.068. IN-PERSON EVALUATION REQUIRED FOR CERTAIN
SERVICES. (a) A medical assistance provider may order or otherwise
authorize the provision of home health services for a recipient
only if the provider has conducted an in-person evaluation of the
recipient within the six-month period preceding the date the order
or other authorization was issued.
(b) A physician, physician assistant, nurse practitioner,
clinical nurse specialist, or certified nurse-midwife that orders
or otherwise authorizes the provision of durable medical equipment
for a recipient in accordance with Chapter 157, Occupations Code,
and other applicable law, including rules, must certify on the
order or other authorization that the person conducted an in-person
evaluation of the recipient within the six-month period preceding
the date the order or other authorization was issued.
(c) The executive commissioner of the Health and Human
Services Commission shall adopt rules necessary to implement this
section.
SECTION 6. Section 531.1131, Government Code, as added by
this Act, applies to the investigation of a fraudulent Medicaid or
child health plan program claim or other program abuse that
commences on or after the effective date of this Act. An
investigation that commences before the effective date of this Act
is governed by the law in effect when the investigation commenced,
and the former law is continued in effect for that purpose.
SECTION 7. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 8. This Act takes effect September 1, 2011.