83R2900 EES-F
By: Eiland H.B. No. 1924
A BILL TO BE ENTITLED
AN ACT
relating to the implementation of certain technology in the Health
and Human Services Commission's claims processing procedures to
prevent fraud, waste, and abuse in the Medicaid and child health
plan programs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter C, Chapter 531, Government Code, is
amended by adding Section 531.118 to read as follows:
Sec. 531.118. IMPLEMENTATION OF TECHNOLOGY SOLUTIONS IN
CLAIMS PROCESSING PROCEDURES TO PREVENT FRAUD, WASTE, AND ABUSE.
(a) To reduce fraud, waste, and abuse in the Medicaid and child
health plan programs, the commission shall implement in the
Medicaid fee-for-service and managed care models and the child
health plan program prepayment fraud prevention solutions to detect
and prevent fraud, waste, and abuse before paying provider claims.
The solutions must include the implementation of:
(1) provider data verification and screening
technology in the commission's claims processing procedures in
order for the commission to verify billing and other information
submitted by a provider with information maintained about the
provider by the commission in a continually updated provider
information database for the purpose of:
(A) automating the commission's procedures for
reviewing claims;
(B) identifying and preventing inappropriate
payments to a deceased, sanctioned, or retired provider or a
provider who is practicing with an expired license; and
(C) identifying and preventing the payment of a
provider at the wrong address; and
(2) predictive modeling and analytics technology in
the commission's claims processing procedures in order for the
commission to have access to comprehensive and accurate information
about Medicaid and child health plan program providers and
recipients and the geographic distribution of those providers and
recipients for the purpose of:
(A) identifying and analyzing billing and
utilization patterns that indicate a high risk for fraudulent
activity;
(B) analyzing claims before payment to minimize
disruptions to the commission's claims processing procedures and to
speed the resolution of claims;
(C) prioritizing claims that likely involve
fraud, waste, or abuse for additional review before payment; and
(D) preventing the payment of claims that
potentially involve fraud, waste, or abuse until the claims have
been verified as valid.
(b) The commission shall collect outcome information
relating to provider reimbursement claims previously paid by the
commission to enhance the predictive modeling and analytics
technology described in Subsection (a)(2).
(c) The commission shall contract with an entity to
initially implement and maintain the data verification and
screening technology and the predictive modeling and analytics
technology described in Subsection (a). To the extent possible, the
commission shall pay for that technology through savings achieved
by the implementation of the technology. The commission may pay an
entity that contracts with the commission to implement or maintain
the technology according to a percentage of achieved savings model,
a per Medicaid or child health plan program recipient per month
model, a per transaction model, a case-rate model, or a blended
model. The commission may specify in a contract with an entity under
this section certain performance measures that must be met before
the entity receives payment under the contract.
SECTION 2. 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 3. This Act takes effect September 1, 2013.