By: Huffman S.B. No. 1803
A BILL TO BE ENTITLED
AN ACT
relating to the Office of the Inspector General.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Amend Section 531.1011, Government Code, as
follows, and not withstanding any other law:
Sec. 531.1011. DEFINITIONS. For purposes of this
subchapter:
(1) "Fraud" means an intentional deception or
misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit to that person
or some other person, including any act that constitutes fraud
under applicable federal or state law.
(2) "Furnished" refers to items or services provided
directly by, or under the direct supervision of, or ordered by a
practitioner or other individual (either as an employee or in the
individual's own capacity), a provider, or other supplier of
services, excluding services ordered by one party but billed for
and provided by or under the supervision of another.
(3) "Hold on payment" means the temporary denial of
reimbursement under the Medicaid program for items or services
furnished by a specified provider.
(4) "Practitioner" means a physician or other
individual licensed under state law to practice the individual's
profession.
(5) "Program exclusion" means the suspension of a
provider from being authorized under the Medicaid program to
request reimbursement of items or services furnished by that
specific provider.
(6) "Provider" means a person, firm, partnership,
corporation, agency, association, institution, or other entity
that was or is approved by the commission to:
(A) provide medical assistance under contract or
provider agreement with the commission; or
(B) provide third-party billing vendor services
under a contract or provider agreement with the commission.
(7) "Appropriate regulatory agency" means, with
respect to a recipient who holds a license issued by a state agency,
the state agency that issued the license. If the recipient does not
hold a license issued by a state agency, then the appropriate
regulatory agency means the State Office of Administrative
Hearings. If the appropriate agency is a board, the board may
appoint a subcommittee to fulfill the board's role.
(8) "Credible allegation of fraud" means:
1(A) an allegation of fraud, from any source,
against a provider; and
(B) that has been communicated to the provider
and to which the provider has had the opportunity to respond; and
(C) that a reasonable provider, in the same field
or discipline as the provider against whom the allegations have
been made, could reasonably conclude that the allegation of fraud
has been substantiated after reviewing the information that is
available to the office with respect to the allegation; or a finding
by the Inspector General. OR:
2.If the Inspector General certifies that a
credible allegation of fraud exists or exists under subsection F-4.
(9) "Preliminary finding of fraud" means:
(A) an allegation of fraud, from any source,
against a provider;
(B) that has been preliminarily investigated by
the office; and
(C) that, based on the office's review of the
allegations, the office's experience with similar providers and any
other relevant facts and circumstances involving the allegations,
lead the office to reasonably determine that an additional
investigation into the allegations is warranted.
SECTION 2. Section 531.102, Government Code, is amended by
amending subsection (f), and adding new subsections (f-1), (f-2),
(f-3) and (j) as follows, and not withstanding any other law.
(f)(1) If the commission receives a complaint of Medicaid
fraud or abuse from any source, the office must conduct an integrity
review to determine whether there is sufficient basis evidence to
warrant a preliminary finding of fraud a full investigation. An
integrity review must begin not later than the 30th day after the
date the commission receives a complaint or has reason to believe
that fraud or abuse has occurred. An integrity review shall be
completed not later than the 90th day after it began.
(2) If the findings of an integrity review give the
office reason to believe that there is sufficient evidence to
warrant a preliminary finding of fraud an incident of fraud or abuse
involving possible criminal conduct has occurred in the Medicaid
program, the office must take the following action, as appropriate,
not later than the 30th day after the completion of the integrity
review, notify the recipient that the office has made a preliminary
determination of fraud with respect to that recipient.
(3)(A) if If a provider is suspected of fraud or abuse
involving criminal conduct, the office must refer the case to the
state's Medicaid fraud control unit, provided that the criminal
referral does not preclude the office from continuing its
investigation of the provider, which investigation may lead to the
imposition of appropriate administrative or civil sanctions; or
(B) if there is reason to believe that a
recipient has defrauded the Medicaid program, the office may
conduct a full investigation of the suspected fraud.
(f-1) (a) If the office notifies a recipient that the office
has made a preliminary finding of fraud with respect to that
recipient under section (f)(2), then the office shall, along with
this notification, provide the recipient with:
(1) the specific facts that form the basis of the
office's preliminary finding of fraud;
(2) a representative sample of any documents that form
the basis of the office's preliminary finding of fraud; and
(3) a document, written in plain English, that
describes the office's processes and procedures for determining
when and how the office determines whether a preliminary finding of
fraud or credible allegation of fraud exists.
(b) The recipient has thirty days after being notified that
the office has made a preliminary finding of fraud with respect to
that recipient to respond to the office. The recipient's response
may include any documentation or any other relevant evidence that
the recipient believes would rebut or refute the office's
preliminary finding of fraud.
(c) If requested by the recipient, the office shall provide
the recipient with an additional thirty days to respond under
subsection (b).
(f-2) (a) If, after reviewing the documentation and other
relevant evidence submitted by a provider under section (f-1), the
office determines that credible allegation of fraud exists, then,
in addition to other instances authorized under state or federal
law, the office shall impose a hold on payment of claims for
reimbursement submitted by the provider
(b) At any time after written request by a provider subject
to a hold on payment under subsection (a), the office shall refer
the hold, and any documentation or other relevant evidence the
office has with respect to the hold to the appropriate regulatory
agency
(c) If the appropriate regulatory agency is the State Office
of Administrative Hearings, then the office shall file a request
with the State Office of Administrative Hearings for an expedited
administrative hearing regarding the hold.
(d) If the appropriate regulatory agency is not the State
Office of Administrative Hearings, then the executive director of
the appropriate regulatory agency shall review the hold and any
documentation and any other relevant evidence related to the hold.
The executive director shall then recommend to the board of the
appropriate regulatory agency whether, based on the executive
director's review of the hold and the documentation and other
relevant evidence submitted by the office, the hold should remain
in place or be dissolved. The board shall take up and consider the
executive director's recommendation under this section at its next
board meeting. A decision by the Board of the appropriate
regulatory agency may be appealed directly to a district court in
Travis County under this subsection.
(f-3) The commission shall adopt rules that allow a provider
subject to a hold on payment under this section other than a hold
requested by the state's Medicaid fraud control unit, to seek an
informal resolution of the issues identified by the office. A
provider may seek an informal resolution under this subsection at
any time.
(j) The office shall post on its publicly available website
a description, in plain English, of the processes and procedures
that the office uses to determine whether to impose a hold on a
recipient under this section.
(f-4) Not withstanding any other provision in this section,
if the Inspector General, after reviewing documentation, or other
relevant evidence regarding a provider, determines that by clear
and convincing evidence that a credible allegation of fraud exists,
then the Inspector General may certify that finding. The Inspector
General may not delegate a certification under this subsection to
any other employee in the Office of Inspector General.
SECTION 3. Subchapter C, Chapter 531, Government Code, is
amended by adding Section 531.118 to read as follows:
Sec.531.118. HEARINGS ON ACTIONS TAKEN BY OFFICE OF INSPECTOR
GENERAL TO RECOVER CERTAIN OVERPAYMENTS UNDER MEDICAID PROGRAM. (a)
A Medicaid provider from whom the commission's office of inspector
general seeks to recover an overpayment made to the provider under
the Medicaid program is entitled to a hearing on a determination
made or other action taken by the office to recover the overpayment.
If there is an overpayment issue, the Office of Inspector General
shall adhere to the following actions:
(b) If the commission receives a complaint of Medicaid
overpayment from any source, the office must conduct an integrity
review to determine whether there is sufficient basis evidence that
an overpayment has been made.
(c) If the office notifies a recipient that the office has
made a finding of overpayment with respect to that recipient under
then the office shall, along with this notification, provide the
recipient with:
(1) the specific facts that form the basis of the
office's preliminary finding of overpayment;
(2) a representative sample of any documents that form
the basis of the office's finding of overpayment; and
(3) a document, written in plain English, that
describes the office's processes and procedures for determining
when and how the office determines whether an overpayment exists.
(d) If, after reviewing the documentation and other
relevant evidence submitted by a provider the office determines
that an overpayment exists, then:
(1) The appropriate regulatory agency as defined in
Sec. 531.1011 (7) is the State Office of Administrative Hearings,
shall file a request with the State Office of Administrative
Hearings for an expedited administrative hearing regarding the
overpayment, or:
(2) The appropriate regulatory agency as defined in
Sec. 531.1011 (7) is not the State Office of Administrative
Hearings, then the executive director of the appropriate regulatory
agency shall review the overpayment and any documentation and any
other relevant evidence related to the overpayment. The executive
director shall then recommend to the board of the appropriate
regulatory agency whether, based on the executive director's review
of the overpayment and the documentation and other relevant
evidence submitted by the office, the overpayment should remain in
place or be dissolved. The board shall take up and consider the
executive director's recommendation under this section at its next
board meeting. A decision by the Board of the appropriate
regulatory agency may be appealed directly to a district court in
Travis County under this subsection.
(3) The office shall post on its publicly available
website a description, in plain English, of the processes and
procedures that the office uses to determine whether to impose a
hold on a recipient under this section.
SECTION 4: Not later than January 1, 2014, the appropriate
regulatory agencies shall adopt the rules necessary to implement
the changes in law made by this Act. These rules shall include a
standard process for all applicable hearings, including an
opportunity for the provider to respond to any allegations.
SECTION 5: Chapter 2001 and 2003 of the Government code do not
apply to hearings that are held by the appropriate regulatory
agencies under this subsection.
SECTION 6. This Act takes effect September 1, 2013.