Texas 2017 - 85th Regular

Texas House Bill HB3596 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	85R3110 LED-D
2	2	By: Muñoz, Jr. H.B. No. 3596
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the Health and Human Services Commission's strategy for
8	8	managing audit resources, including procedures for auditing and
9	9	collecting payments from Medicaid managed care organizations.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Chapter 533, Government Code, is amended by
12	12	adding Subchapter B to read as follows:
13	13	SUBCHAPTER B. STRATEGY FOR MANAGING AUDIT RESOURCES
14	14	Sec. 533.051. DEFINITIONS. In this subchapter:
15	15	(1) "Accounts receivable tracking system" means the
16	16	system the commission uses to track experience rebates and other
17	17	payments collected from managed care organizations.
18	18	(2) "Agreed-upon procedures engagement" means an
19	19	evaluation of a managed care organization's financial statistical
20	20	reports or other data conducted by an independent auditing firm
21	21	engaged by the commission as agreed in the managed care
22	22	organization's contract with the commission.
23	23	(3) "Experience rebate" means the amount a managed
24	24	care organization is required to pay the state according to the
25	25	graduated rebate method described in the managed care
26	26	organization's contract with the commission.
27	27	(4) "External quality review organization" means an
28	28	organization that performs an external quality review of a managed
29	29	care organization in accordance with 42 C.F.R. Section 438.350.
30	30	Sec. 533.052. OVERALL STRATEGY FOR MANAGING AUDIT
31	31	RESOURCES. The commission shall develop and implement an overall
32	32	strategy for planning, managing, and coordinating audit resources
33	33	that the commission uses to verify the accuracy and reliability of
34	34	program and financial information reported by managed care
35	35	organizations.
36	36	Sec. 533.053. PERFORMANCE AUDIT SELECTION PROCESS AND
37	37	FOLLOW-UP. (a) To improve the commission's processes for
38	38	performance audits of managed care organizations, the commission
39	39	shall:
40	40	(1) document the process by which the commission
41	41	selects managed care organizations to audit;
42	42	(2) include previous audit coverage as a risk factor
43	43	in selecting managed care organizations to audit; and
44	44	(3) prioritize the highest risk managed care
45	45	organizations to audit.
46	46	(b) To verify that managed care organizations correct
47	47	negative performance audit findings, the commission shall:
48	48	(1) establish a process to:
49	49	(A) document how the commission follows up on
50	50	negative performance audit findings; and
51	51	(B) verify that managed care organizations
52	52	implement performance audit recommendations; and
53	53	(2) establish and implement policies and procedures
54	54	to:
55	55	(A) determine under what circumstances the
56	56	commission must issue a corrective action plan to a managed care
57	57	organization based on a performance audit; and
58	58	(B) follow up on the managed care organization's
59	59	implementation of the corrective action plan.
60	60	Sec. 533.054. AGREED-UPON PROCEDURES ENGAGEMENTS AND
61	61	CORRECTIVE ACTION PLANS. To enhance the commission's use of
62	62	agreed-upon procedures engagements to identify managed care
63	63	organizations' performance and compliance issues, the commission
64	64	shall:
65	65	(1) ensure that financial risks identified in
66	66	agreed-upon procedures engagements are adequately and consistently
67	67	addressed; and
68	68	(2) establish policies and procedures to determine
69	69	under what circumstances the commission must issue a corrective
70	70	action plan based on an agreed-upon procedures engagement.
71	71	Sec. 533.055. AUDITS OF PHARMACY BENEFIT MANAGERS. To
72	72	obtain greater assurance about the effectiveness of pharmacy
73	73	benefit managers' internal controls and compliance with state
74	74	requirements, the commission shall:
75	75	(1) periodically audit each pharmacy benefit manager
76	76	that contracts with a managed care organization or require each
77	77	managed care organization to periodically audit each pharmacy
78	78	benefit manager that contracts with the managed care organization;
79	79	and
80	80	(2) develop, document, and implement a monitoring
81	81	process to ensure that managed care organizations correct and
82	82	resolve negative findings reported in performance audits or
83	83	agreed-upon procedures engagements of pharmacy benefit managers.
84	84	Sec. 533.056. COLLECTION OF COSTS FOR AUDIT-RELATED
85	85	SERVICES. The commission shall develop, document, and implement
86	86	billing processes in the Medicaid and CHIP services department of
87	87	the commission to ensure that managed care organizations reimburse
88	88	the commission for audit-related services as required by contract.
89	89	Sec. 533.057. COLLECTION ACTIVITIES RELATED TO PROFIT
90	90	SHARING. To strengthen the commission's process for collecting
91	91	shared profits from managed care organizations, the commission
92	92	shall develop, document, and implement monitoring processes in the
93	93	Medicaid and CHIP services department of the commission to ensure
94	94	that the commission:
95	95	(1) identifies experience rebates deposited in the
96	96	commission's suspense account and timely transfers those rebates to
97	97	the appropriate accounts; and
98	98	(2) timely follows up on and resolves disputes over
99	99	experience rebates claimed by managed care organizations.
100	100	Sec. 533.058. USE OF INFORMATION FROM EXTERNAL QUALITY
101	101	REVIEWS. (a) To enhance the commission's monitoring of managed
102	102	care organizations, the commission shall use the information
103	103	provided by the external quality review organization, including:
104	104	(1) detailed data from results of surveys of Medicaid
105	105	recipients and, if applicable, child health plan program enrollees,
106	106	caregivers of those recipients and enrollees, and Medicaid and, as
107	107	applicable, child health plan program providers; and
108	108	(2) the validation results of matching paid claims
109	109	data with medical records.
110	110	(b) The commission shall document how the commission uses
111	111	the information described by Subsection (a) to monitor managed care
112	112	organizations.
113	113	Sec. 533.059. SECURITY AND PROCESSING CONTROLS OVER
114	114	INFORMATION TECHNOLOGY SYSTEMS. The commission shall:
115	115	(1) strengthen user access controls for the
116	116	commission's accounts receivable tracking system and network
117	117	folders that the commission uses to manage the collection of
118	118	experience rebates;
119	119	(2) document daily reconciliations of deposits
120	120	recorded in the accounts receivable tracking system to the
121	121	transactions processed in:
122	122	(A) the commission's cost accounting system for
123	123	all health and human services agencies; and
124	124	(B) the uniform statewide accounting system; and
125	125	(3) develop, document, and implement a process to
126	126	ensure that the commission formally documents:
127	127	(A) all programming changes made to the accounts
128	128	receivable tracking system; and
129	129	(B) the authorization and testing of the changes
130	130	described by Paragraph (A).
131	131	SECTION 2. As soon as practicable after the effective date
132	132	of this Act, the executive commissioner of the Health and Human
133	133	Services Commission shall adopt the rules necessary to implement
134	134	Subchapter B, Chapter 533, Government Code, as added by this Act.
135	135	SECTION 3. This Act takes effect September 1, 2017.