Texas 2017 - 85th Regular

Texas Senate Bill SB293 Compare Versions

Version 1 (Old)

Version 2 (New)

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1		-	By: Hinojosa, Schwertner S.B. No. 293
2		-	(In the Senate - Filed December 14, 2016; January 30, 2017,
3		-	read first time and referred to Committee on Health & Human
4		-	Services; March 30, 2017, reported adversely, with favorable
5		-	Committee Substitute by the following vote: Yeas 9, Nays 0;
6		-	March 30, 2017, sent to printer.)
7		-	Click here to see the committee vote
8		-	COMMITTEE SUBSTITUTE FOR S.B. No. 293 By: Uresti
	1	+	By: Hinojosa, Creighton S.B. No. 293
	2	+	Schwertner
9	3
10	4
11	5		A BILL TO BE ENTITLED
12	6		AN ACT
13	7		relating to the proof required to impose payment holds in certain
14	8		cases of alleged fraud by Medicaid providers.
15	9		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
16	10		SECTION 1. Section 531.102(g), Government Code, is amended
17	11		to read as follows:
18	12		(g)(1) Whenever the office learns or has reason to suspect
19	13		that a provider's records are being withheld, concealed, destroyed,
20	14		fabricated, or in any way falsified, the office shall immediately
21	15		refer the case to the state's Medicaid fraud control unit. However,
22	16		such criminal referral does not preclude the office from continuing
23	17		its investigation of the provider, which investigation may lead to
24	18		the imposition of appropriate administrative or civil sanctions.
25	19		(2) As authorized under state and federal law, and
26	20		except as provided by Subdivisions (8) and (9), the office shall
27	21		impose without prior notice a payment hold on claims for
28	22		reimbursement submitted by a provider only to compel production of
29	23		records, when requested by the state's Medicaid fraud control unit,
30	24		or on the determination that a credible allegation of fraud exists,
31	25		subject to Subsections (l) and (m), as applicable. The payment hold
32	26		is a serious enforcement tool that the office imposes to mitigate
33	27		ongoing financial risk to the state. A payment hold imposed under
34	28		this subdivision takes effect immediately. The office must notify
35	29		the provider of the payment hold in accordance with 42 C.F.R.
36	30		Section 455.23(b) and, except as provided by that regulation, not
37	31		later than the fifth day after the date the office imposes the
38	32		payment hold. In addition to the requirements of 42 C.F.R. Section
39	33		455.23(b), the notice of payment hold provided under this
40	34		subdivision must also include:
41	35		(A) the specific basis for the hold, including
42	36		identification of the claims supporting the allegation at that
43	37		point in the investigation, a representative sample of any
44	38		documents that form the basis for the hold, and a detailed summary
45	39		of the office's evidence relating to the allegation;
46	40		(B) a description of administrative and judicial
47	41		due process rights and remedies, including the provider's option to
48	42		seek informal resolution, the provider's right to seek a formal
49	43		administrative appeal hearing, or that the provider may seek both;
50	44		and
51	45		(C) a detailed timeline for the provider to
52	46		pursue the rights and remedies described in Paragraph (B).
53	47		(3) On timely written request by a provider subject to
54	48		a payment hold under Subdivision (2), other than a hold requested by
55	49		the state's Medicaid fraud control unit, the office shall file a
56	50		request with the State Office of Administrative Hearings for an
57	51		expedited administrative hearing regarding the hold not later than
58	52		the third day after the date the office receives the provider's
59	53		request. The provider must request an expedited administrative
60	54		hearing under this subdivision not later than the 10th day after the
61	55		date the provider receives notice from the office under Subdivision
62	56		(2). The State Office of Administrative Hearings shall hold the
63	57		expedited administrative hearing not later than the 45th day after
64	58		the date the State Office of Administrative Hearings receives the
65	59		request for the hearing. In a hearing held under this subdivision:
66	60		(A) the provider and the office are each limited
67	61		to four hours of testimony, excluding time for responding to
68	62		questions from the administrative law judge;
69	63		(B) the provider and the office are each entitled
70	64		to two continuances under reasonable circumstances; and
71	65		(C) the office is required to show probable cause
72	66		that the credible allegation of fraud that is the basis of the
73	67		payment hold has an indicia of reliability and that continuing to
74	68		pay the provider presents:
75	69		(i) an ongoing significant financial risk
76	70		that [to] the state may lose more than $100,000; or [and]
77	71		(ii) a threat to the integrity of Medicaid
78	72		as defined in rules adopted by the executive commissioner, in
79	73		consultation with the office.
80	74		(4) The office is responsible for the costs of a
81	75		hearing held under Subdivision (3), but a provider is responsible
82	76		for the provider's own costs incurred in preparing for the hearing.
83	77		(5) In a hearing held under Subdivision (3), the
84	78		administrative law judge shall decide if the payment hold should
85	79		continue but may not adjust the amount or percent of the payment
86	80		hold. Notwithstanding any other law, including Section
87	81		2001.058(e), the decision of the administrative law judge is final
88	82		and may not be appealed.
89	83		(6) The executive commissioner, in consultation with
90	84		the office, shall adopt rules that allow a provider subject to a
91	85		payment hold under Subdivision (2), other than a hold requested by
92	86		the state's Medicaid fraud control unit, to seek an informal
93	87		resolution of the issues identified by the office in the notice
94	88		provided under that subdivision. A provider must request an
95	89		initial informal resolution meeting under this subdivision not
96	90		later than the deadline prescribed by Subdivision (3) for
97	91		requesting an expedited administrative hearing. On receipt of a
98	92		timely request, the office shall decide whether to grant the
99	93		provider's request for an initial informal resolution meeting, and
100	94		if the office decides to grant the request, the office shall
101	95		schedule the initial informal resolution meeting. The office shall
102	96		give notice to the provider of the time and place of the initial
103	97		informal resolution meeting. A provider may request a second
104	98		informal resolution meeting after the date of the initial informal
105	99		resolution meeting. On receipt of a timely request, the office
106	100		shall decide whether to grant the provider's request for a second
107	101		informal resolution meeting, and if the office decides to grant the
108	102		request, the office shall schedule the second informal resolution
109	103		meeting. The office shall give notice to the provider of the time
110	104		and place of the second informal resolution meeting. A provider
111	105		must have an opportunity to provide additional information before
112	106		the second informal resolution meeting for consideration by the
113	107		office. A provider's decision to seek an informal resolution under
114	108		this subdivision does not extend the time by which the provider must
115	109		request an expedited administrative hearing under Subdivision (3).
116	110		The informal resolution process shall run concurrently with the
117	111		administrative hearing process, and the informal resolution
118	112		process shall be discontinued once the State Office of
119	113		Administrative Hearings issues a final determination on the payment
120	114		hold.
121	115		(7) The office shall, in consultation with the state's
122	116		Medicaid fraud control unit, establish guidelines under which
123	117		program exclusions:
124	118		(A) may permissively be imposed on a provider; or
125	119		(B) shall automatically be imposed on a provider.
126	120		(7-a) The office shall, in consultation with the
127	121		state's Medicaid fraud control unit, establish guidelines
128	122		regarding the imposition of payment holds authorized under
129	123		Subdivision (2).
130	124		(8) In accordance with 42 C.F.R. Sections 455.23(e)
131	125		and (f), on the determination that a credible allegation of fraud
132	126		exists, the office may find that good cause exists to not impose a
133	127		payment hold, to not continue a payment hold, to impose a payment
134	128		hold only in part, or to convert a payment hold imposed in whole to
135	129		one imposed only in part, if any of the following are applicable:
136	130		(A) law enforcement officials have specifically
137	131		requested that a payment hold not be imposed because a payment hold
138	132		would compromise or jeopardize an investigation;
139	133		(B) available remedies implemented by the state
140	134		other than a payment hold would more effectively or quickly protect
141	135		Medicaid funds;
142	136		(C) the office determines, based on the
143	137		submission of written evidence by the provider who is the subject of
144	138		the payment hold, that the payment hold should be removed;
145	139		(D) Medicaid recipients' access to items or
146	140		services would be jeopardized by a full or partial payment hold
147	141		because the provider who is the subject of the payment hold:
148	142		(i) is the sole community physician or the
149	143		sole source of essential specialized services in a community; or
150	144		(ii) serves a large number of Medicaid
151	145		recipients within a designated medically underserved area;
152	146		(E) the attorney general declines to certify that
153	147		a matter continues to be under investigation; or
154	148		(F) the office determines that a full or partial
155	149		payment hold is not in the best interests of Medicaid.
156	150		(9) The office may not impose a payment hold on claims
157	151		for reimbursement submitted by a provider for medically necessary
158	152		services for which the provider has obtained prior authorization
159	153		from the commission or a contractor of the commission unless the
160	154		office has evidence that the provider has materially misrepresented
161	155		documentation relating to those services.
162	156		SECTION 2. As soon as practicable after the effective date
163	157		of this Act, the executive commissioner of the Health and Human
164	158		Services Commission shall adopt the rules required by Section
165	159		531.102(g)(3)(C)(ii), Government Code, as added by this Act.
166	160		SECTION 3. If before implementing any provision of this Act
167	161		a state agency determines that a waiver or authorization from a
168	162		federal agency is necessary for implementation of that provision,
169	163		the agency affected by the provision shall request the waiver or
170	164		authorization and may delay implementing that provision until the
171	165		waiver or authorization is granted.
172	166		SECTION 4. This Act takes effect immediately if it receives
173	167		a vote of two-thirds of all the members elected to each house, as
174	168		provided by Section 39, Article III, Texas Constitution. If this
175	169		Act does not receive the vote necessary for immediate effect, this
176	170		Act takes effect September 1, 2017.
177		-	* * * * *