84R25644 JSL-F
By: Klick, et al. H.B. No. 3917
Substitute the following for H.B. No. 3917:
By: Raymond C.S.H.B. No. 3917
A BILL TO BE ENTITLED
AN ACT
relating to the recoupment of payments on certain provider claims
made under the Medicaid program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 32, Human Resources Code,
is amended by adding Sections 32.0631 and 32.0632 to read as
follows:
Sec. 32.0631. POLICIES RELATED TO RECOUPMENT OF PAYMENTS.
(a) Notwithstanding any other law the commission shall, subject to
Subsection (b), develop and implement policies to prevent
recoupment of an improper payment that was made to a provider for a
claim for medical services made under the medical assistance
program if the provider:
(1) actually provided a medical service reimbursable
under the medical assistance program; and
(2) submitted a clean claim as required under the
medical assistance program.
(b) The policies developed under Subsection (a) must:
(1) allow the recoupment of an improper payment in the
case of fraud or abuse; and
(2) require that when recoupment is allowed, the
amount of a recouped payment may be no greater than the difference
between the payment amount made to the provider that is subject to
recoupment and the reimbursement rate in effect on the date the
service was provided.
(c) To reduce the incidence of improper payments under the
medical assistance program, the commission shall develop and
implement methods to improve communication between:
(1) the commission;
(2) providers under the program;
(3) entities with which the commission contracts to
administer claims under the program; and
(4) managed care organizations with which the
commission contracts to provide medical services to recipients
under the program.
(d) The methods to improve communication under Subsection
(c) must include requirements to provide necessary information to a
provider regarding:
(1) how, and to whom, the provider must submit a clean
claim; and
(2) how the provider may file a complaint with the
commission regarding a payment dispute, including a complaint that
may be filed after the provider has exhausted all rights to appeal.
Sec. 32.0632. PROCESSES AND IMPROVEMENTS RELATED TO
OVERPAYMENT OF CLAIMS. (a) The commission shall conduct separate
studies to:
(1) evaluate the feasibility of implementing a process
that allows an entity with which the commission contracts to
administer claims under the medical assistance program, or a
managed care organization with which the commission contracts to
provide services to recipients under the medical assistance
program, that makes an improper payment on a claim that is subject
to Section 32.0631, to have a right of subrogation against another
entity, including a managed care organization, that is or would
have been responsible for payment of the claim had the claim been
properly filed with that entity; and
(2) identify improvements that should be made to
eligibility determination processes and other administrative
procedures in order to reduce the incidence of retroactive
disenrollment from the medical assistance program that can result
in improper payments.
(b) If, as a result of each study conducted under this
section, the commission determines that implementation of the
studied process or improvements, as applicable, would be feasible
and cost-effective to implement, the commission shall,
notwithstanding any other law, implement the process or
improvements. If the commission implements the process or
improvements, the commission shall modify contracts with an entity
with which the commission contracts to administer claims and
managed care organizations to the extent possible and as necessary
for that implementation.
(c) Not later than December 1, 2016, the commission shall
submit a report to each standing committee of the senate and house
of representatives having primary jurisdiction over the medical
assistance program detailing the results of each study conducted
under this section and, if the commission implemented the
applicable process or improvements in accordance with Subsection
(b), an analysis of the effectiveness of the implementation in
reducing overpayments. This subsection expires September 1, 2017.
SECTION 2. Section 32.0631, Human Resources Code, as added
by this Act, applies only to improper payments for claims made under
the medical assistance program under Chapter 32, Human Resources
Code, that are made on or after the effective date of this Act. A
claim made before the effective date of this Act is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
SECTION 3. 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 4. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2015.