85R30576 LED/KFF-D
By: Buckingham S.B. No. 894
(Muñoz, Jr.)
Substitute the following for S.B. No. 894: No.
A BILL TO BE ENTITLED
AN ACT
relating to the Health and Human Services Commission's auditing of
Medicaid managed care organizations and auditing and collection of
Medicaid payments, including the commission's management of audit
resources.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.024172, Government Code, is amended
to read as follows:
Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM;
REIMBURSEMENT OF CERTAIN RELATED CLAIMS. (a) Subject to
Subsection (g), [In this section, "acute nursing services" has the
meaning assigned by Section 531.02417.
[(b) If it is cost-effective and feasible,] the commission
shall, in accordance with federal law, implement an electronic
visit verification system to electronically verify [and document,]
through a telephone, global positioning, or computer-based system
that personal care services or attendant care services provided to
recipients under Medicaid, including personal care services or
attendant care services provided under the Texas Health Care
Transformation and Quality Improvement Program waiver issued under
Section 1115 of the federal Social Security Act (42 U.S.C. Section
1315) or any other Medicaid waiver program, are provided to
recipients in accordance with a prior authorization or plan of
care. The electronic visit verification system implemented under
this subsection must allow for verification of only the following[,
basic] information relating to the delivery of Medicaid [acute
nursing] services[, including]:
(1) the type of service provided [the provider's
name];
(2) the name of the recipient to whom the service is
provided [the recipient's name]; [and]
(3) the date and times [time] the provider began
[begins] and ended the [ends each] service delivery visit;
(4) the location, including the address, at which the
service was provided;
(5) the name of the individual who provided the
service; and
(6) other information the commission determines is
necessary to ensure the accurate adjudication of Medicaid claims.
(b) The commission shall establish minimum requirements for
third-party entities seeking to provide electronic visit
verification system services to health care providers providing
Medicaid services and must certify that a third-party entity
complies with those minimum requirements before the entity may
provide electronic visit verification system services to a health
care provider.
(c) The commission shall inform each Medicaid recipient who
receives personal care services or attendant care services that the
health care provider providing the services and the recipient are
each required to comply with the electronic visit verification
system. A managed care organization that contracts with the
commission to provide health care services to Medicaid recipients
described by this subsection shall also inform recipients enrolled
in a managed care plan offered by the organization of those
requirements.
(d) In implementing the electronic visit verification
system:
(1) subject to Subsection (e), the executive
commissioner shall adopt compliance standards for health care
providers; and
(2) the commission shall ensure that:
(A) the information required to be reported by
health care providers is standardized across managed care
organizations that contract with the commission to provide health
care services to Medicaid recipients and across commission
programs; and
(B) time frames for the maintenance of electronic
visit verification data by health care providers align with claims
payment time frames.
(e) In establishing compliance standards for health care
providers under this section, the executive commissioner shall
consider:
(1) the administrative burdens placed on health care
providers required to comply with the standards; and
(2) the benefits of using emerging technologies for
ensuring compliance, including Internet-based, mobile
telephone-based, and global positioning-based technologies.
(f) A health care provider that provides personal care
services or attendant care services to Medicaid recipients shall:
(1) use an electronic visit verification system to
document the provision of those services;
(2) comply with all documentation requirements
established by the commission;
(3) comply with applicable federal and state laws
regarding confidentiality of recipients' information;
(4) ensure that the commission or the managed care
organization with which a claim for reimbursement for a service is
filed may review electronic visit verification system
documentation related to the claim or obtain a copy of that
documentation at no charge to the commission or the organization;
and
(5) at any time, allow the commission or a managed care
organization with which a health care provider contracts to provide
health care services to recipients enrolled in the organization's
managed care plan to have direct, on-site access to the electronic
visit verification system in use by the health care provider.
(g) The commission may recognize a health care provider's
proprietary electronic visit verification system as complying with
this section and allow the health care provider to use that system
for a period determined by the commission if the commission
determines that the system:
(1) complies with all necessary data submission,
exchange, and reporting requirements established under this
section;
(2) meets all other standards and requirements
established under this section; and
(3) has been in use by the health care provider since
at least June 1, 2014.
(h) The commission or a managed care organization that
contracts with the commission to provide health care services to
Medicaid recipients may not pay a claim for reimbursement for
personal care services or attendant care services provided to a
recipient unless the information from the electronic visit
verification system corresponds with the information contained in
the claim and the services were provided consistent with a prior
authorization or plan of care. A previously paid claim is subject
to retrospective review and recoupment if unverified.
(i) The commission shall create a stakeholder work group
comprised of representatives of affected health care providers,
managed care organizations, and Medicaid recipients and
periodically solicit from that work group input regarding the
ongoing operation of the electronic visit verification system under
this section.
(j) The executive commissioner may adopt rules necessary to
implement this section.
SECTION 2. Section 531.120, Government Code, is amended by
adding Subsection (c) to read as follows:
(c) The commission shall provide the notice required by
Subsection (a) to a provider that is a hospital not later than the
90th day before the date the overpayment or debt that is the subject
of the notice must be paid.
SECTION 3. Chapter 533, Government Code, is amended by
adding Subchapter B to read as follows:
SUBCHAPTER B. STRATEGY FOR MANAGING AUDIT RESOURCES
Sec. 533.051. DEFINITIONS. In this subchapter:
(1) "Accounts receivable tracking system" means the
system the commission uses to track experience rebates and other
payments collected from managed care organizations.
(2) "Agreed-upon procedures engagement" means an
evaluation of a managed care organization's financial statistical
reports or other data conducted by an independent auditing firm
engaged by the commission as agreed in the managed care
organization's contract with the commission.
(3) "Experience rebate" means the amount a managed
care organization is required to pay the state according to the
graduated rebate method described in the managed care
organization's contract with the commission.
(4) "External quality review organization" means an
organization that performs an external quality review of a managed
care organization in accordance with 42 C.F.R. Section 438.350.
Sec. 533.052. APPLICABILITY AND CONSTRUCTION OF
SUBCHAPTER. This subchapter does not apply to and may not be
construed as affecting the conduct of audits by the commission's
office of inspector general under the authority provided by
Subchapter C, Chapter 531, including an audit of a managed care
organization conducted by the office after coordinating the
office's audit and oversight activities with the commission as
required by Section 531.102(q), as added by Chapter 837 (S.B. 200),
Acts of the 84th Legislature, Regular Session, 2015.
Sec. 533.053. OVERALL STRATEGY FOR MANAGING AUDIT
RESOURCES. The commission shall develop and implement an overall
strategy for planning, managing, and coordinating audit resources
that the commission uses to verify the accuracy and reliability of
program and financial information reported by managed care
organizations.
Sec. 533.054. PERFORMANCE AUDIT SELECTION PROCESS AND
FOLLOW-UP. (a) To improve the commission's processes for
performance audits of managed care organizations, the commission
shall:
(1) document the process by which the commission
selects managed care organizations to audit;
(2) include previous audit coverage as a risk factor
in selecting managed care organizations to audit; and
(3) prioritize the highest risk managed care
organizations to audit.
(b) To verify that managed care organizations correct
negative performance audit findings, the commission shall:
(1) establish a process to:
(A) document how the commission follows up on
negative performance audit findings; and
(B) verify that managed care organizations
implement performance audit recommendations; and
(2) establish and implement policies and procedures
to:
(A) determine under what circumstances the
commission must issue a corrective action plan to a managed care
organization based on a performance audit; and
(B) follow up on the managed care organization's
implementation of the corrective action plan.
Sec. 533.055. AGREED-UPON PROCEDURES ENGAGEMENTS AND
CORRECTIVE ACTION PLANS. To enhance the commission's use of
agreed-upon procedures engagements to identify managed care
organizations' performance and compliance issues, the commission
shall:
(1) ensure that financial risks identified in
agreed-upon procedures engagements are adequately and consistently
addressed; and
(2) establish policies and procedures to determine
under what circumstances the commission must issue a corrective
action plan based on an agreed-upon procedures engagement.
Sec. 533.056. AUDITS OF PHARMACY BENEFIT MANAGERS. To
obtain greater assurance about the effectiveness of pharmacy
benefit managers' internal controls and compliance with state
requirements, the commission shall:
(1) periodically audit each pharmacy benefit manager
that contracts with a managed care organization; and
(2) develop, document, and implement a monitoring
process to ensure that managed care organizations correct and
resolve negative findings reported in performance audits or
agreed-upon procedures engagements of pharmacy benefit managers.
Sec. 533.057. COLLECTION OF COSTS FOR AUDIT-RELATED
SERVICES. The commission shall develop, document, and implement
billing processes in the Medicaid and CHIP services department of
the commission to ensure that managed care organizations reimburse
the commission for audit-related services as required by contract.
Sec. 533.058. COLLECTION ACTIVITIES RELATED TO PROFIT
SHARING. To strengthen the commission's process for collecting
shared profits from managed care organizations, the commission
shall develop, document, and implement monitoring processes in the
Medicaid and CHIP services department of the commission to ensure
that the commission:
(1) identifies experience rebates deposited in the
commission's suspense account and timely transfers those rebates to
the appropriate accounts; and
(2) timely follows up on and resolves disputes over
experience rebates claimed by managed care organizations.
Sec. 533.059. USE OF INFORMATION FROM EXTERNAL QUALITY
REVIEWS. (a) To enhance the commission's monitoring of managed
care organizations, the commission shall use the information
provided by the external quality review organization, including:
(1) detailed data from results of surveys of Medicaid
recipients and, if applicable, child health plan program enrollees,
caregivers of those recipients and enrollees, and Medicaid and, as
applicable, child health plan program providers; and
(2) the validation results of matching paid claims
data with medical records.
(b) The commission shall document how the commission uses
the information described by Subsection (a) to monitor managed care
organizations.
Sec. 533.060. SECURITY AND PROCESSING CONTROLS OVER
INFORMATION TECHNOLOGY SYSTEMS. The commission shall:
(1) strengthen user access controls for the
commission's accounts receivable tracking system and network
folders that the commission uses to manage the collection of
experience rebates;
(2) document daily reconciliations of deposits
recorded in the accounts receivable tracking system to the
transactions processed in:
(A) the commission's cost accounting system for
all health and human services agencies; and
(B) the uniform statewide accounting system; and
(3) develop, document, and implement a process to
ensure that the commission formally documents:
(A) all programming changes made to the accounts
receivable tracking system; and
(B) the authorization and testing of the changes
described by Paragraph (A).
SECTION 4. As soon as practicable after the effective date
of this Act:
(1) the Health and Human Services Commission shall
implement an electronic visit verification system in accordance
with Section 531.024172, Government Code, as amended by this Act;
and
(2) the executive commissioner of the Health and Human
Services Commission shall adopt the rules necessary to implement
Subchapter B, Chapter 533, Government Code, as added by this Act.
SECTION 5. 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 6. This Act takes effect September 1, 2017.