85R23202 MM-D
By: Raymond H.B. No. 2969
Substitute the following for H.B. No. 2969:
By: Keough C.S.H.B. No. 2969
A BILL TO BE ENTITLED
AN ACT
relating to fraud, waste, and abuse in Medicaid and other health and
human services programs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Sections 531.102(j) and (k), Government Code,
are amended to read as follows:
(j) The office shall prepare a final report on each audit,
inspection, or investigation conducted under this section. The
final report must include:
(1) a summary of the activities performed by the
office in conducting the audit, inspection, or investigation;
(2) a statement regarding whether the audit,
inspection, or investigation resulted in a finding of any
wrongdoing; and
(3) a description of any findings of wrongdoing.
(k) A final report on an audit, inspection, or investigation
is subject to required disclosure under Chapter 552. All
information and materials compiled during the audit, inspection, or
investigation remain confidential and not subject to required
disclosure in accordance with Section 531.1021(g). A confidential
draft report on an audit, inspection, or investigation that
concerns the death of a child may be shared with the Department of
Family and Protective Services. A draft report that is shared with
the Department of Family and Protective Services remains
confidential and is not subject to disclosure under Chapter 552.
SECTION 2. Section 531.1021(g), Government Code, is amended
to read as follows:
(g) All information and materials subpoenaed or compiled by
the office in connection with an audit, inspection, or
investigation or by the office of the attorney general in
connection with a Medicaid fraud investigation are confidential and
not subject to disclosure under Chapter 552, and not subject to
disclosure, discovery, subpoena, or other means of legal compulsion
for their release to anyone other than the office or the attorney
general or their employees or agents involved in the audit,
inspection, or investigation conducted by the office or the
attorney general, except that this information may be disclosed to
the state auditor's office, law enforcement agencies, and other
entities as permitted by other law.
SECTION 3. The heading to Section 531.106, Government Code,
is amended to read as follows:
Sec. 531.106. LEARNING, [OR] NEURAL NETWORK, OR OTHER
TECHNOLOGY.
SECTION 4. Sections 531.106(a), (c), and (g), Government
Code, are amended to read as follows:
(a) The commission shall use learning, [or] neural network,
or other technology to identify and deter fraud in Medicaid
throughout this state.
(c) The data used for data [neural network] processing shall
be maintained as an independent subset for security purposes.
(g) Each month, the [learning or neural network] technology
implemented under this section must match vital statistics unit
death records with Medicaid claims filed by a provider. If the
commission determines that a provider has filed a claim for
services provided to a person after the person's date of death, as
determined by the vital statistics unit death records, the
commission shall refer the case for investigation to the
commission's office of inspector general.
SECTION 5. Section 531.1061(b), Government Code, is amended
to read as follows:
(b) For each case of suspected fraud, abuse, or insufficient
quality of care identified by the [learning or neural network]
technology required under Section 531.106, the automated fraud
investigation tracking system must:
(1) receive electronically transferred records
relating to the identified case from the [learning or neural
network] technology;
(2) record the details and monitor the status of an
investigation of the identified case, including maintaining a
record of the beginning and completion dates for each phase of the
case investigation;
(3) generate documents and reports related to the
status of the case investigation; and
(4) generate standard letters to a provider regarding
the status or outcome of an investigation.
SECTION 6. Section 531.1131, Government Code, is amended by
amending Subsections (a), (b), and (c) and adding Subsections
(c-1), (c-2), and (c-3) to read as follows:
(a) If a managed care organization [organization's special
investigative unit under Section 531.113(a)(1)] or an [the] entity
with which the managed care organization contracts under Section
531.113(a)(2) discovers fraud or abuse in Medicaid or the child
health plan program, the organization [unit] or entity shall:
(1) immediately submit written notice to [and
contemporaneously notify] the commission's office of inspector
general and the office of the attorney general in the form and
manner prescribed by the office of inspector general and containing
a detailed description of the fraud or abuse and each payment made
to a provider as a result of the fraud or abuse;
(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
[organization's special investigative unit] or the 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 organization [unit] or entity notified the commission's
office of inspector general and the office of the attorney general
under Subsection (a)(1), the organization [unit] or entity receives
a notice from either office indicating that the organization [unit]
or entity is not authorized to proceed with recovery efforts.
(c) A managed care organization may retain one-half of any
money recovered under Subsection (a)(2) by the organization
[organization's special investigative unit] or the contracted
entity described by Subsection (a). The managed care organization
shall remit the remaining amount of money recovered under
Subsection (a)(2) to the commission's office of inspector general.
(c-1) If the commission's office of inspector general
notifies a managed care organization under Subsection (b), proceeds
with recovery efforts, and recovers all or part of the payments the
organization identified as required by Subsection (a)(1), the
organization is entitled to one-half of the amount recovered for
each payment the organization identified after any applicable
federal share is deducted. The managed care organization may not
receive more than one-half of the total amount of money recovered
after any applicable federal share is deducted.
(c-2) Notwithstanding any provision of this section, if the
commission's office of inspector general discovers fraud, waste, or
abuse in Medicaid or the child health plan program in the
performance of its duties, the office may recover payments made to a
provider as a result of the fraud, waste, or abuse as otherwise
provided by this subchapter.
(c-3) With respect to fraud or abuse alleged in any notice
received under Subsection (a), the commission's office of inspector
general shall coordinate with appropriate managed care
organizations to ensure that the office and an organization or an
entity with which an organization contracts under Section
531.113(a)(2) do not both simultaneously pursue recovery efforts
under this section for the same case of fraud, waste, or abuse.
SECTION 7. Section 531.1131, Government Code, as amended by
this Act, applies only to an amount of money recovered on or after
the effective date of this Act. An amount of money recovered before
the effective date of this Act is governed by the law in effect
immediately before that date, and that law is continued in effect
for that purpose.
SECTION 8. 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 9. 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, 2017.