S.B. No. 894
AN ACT
relating to auditing and verification of information under certain
health and human services programs, including the collection of
certain payments following an investigation.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 321.013, Government Code, is amended by
adding Subsection (m) to read as follows:
(m) In devising the audit plan under Subsection (c), the
State Auditor shall consider the performance of audits of programs
operated by health and human services agencies that:
(1) have not recently received audit coverage; and
(2) have expenditures of less than $100 million per
year.
SECTION 2. Section 531.024172, Government Code, is amended
to read as follows:
Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM.
(a) Not later than March 31, 2018, the commission shall conduct a
review of the electronic visit verification system in use under
this section on August 31, 2017. Notwithstanding any other
provision of this section, the commission is required to implement
a change in law made to this section by S.B. 894, Acts of the 85th
Legislature, Regular Session, 2017, only if the commission
determines the implementation is appropriate based on the findings
of the review. The commission may combine the review required by
this subsection with any similar review required to be conducted by
the commission.
(b) 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, attendant care services, or other
services identified by the commission that are 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.
(c) The commission shall inform each Medicaid recipient who
receives personal care services, attendant care services, or other
services identified by the commission 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;
(B) processes required by managed care
organizations to retrospectively correct data are standardized and
publicly accessible to health care providers; and
(C) standardized processes are established for
addressing the failure of a managed care organization to provide a
timely authorization for delivering services necessary to ensure
continuity of care.
(e) In establishing compliance standards for health care
providers under Subsection (d), 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, attendant care services, or other services identified by
the commission 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 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.
(i) The executive commissioner may adopt rules necessary to
implement this section.
SECTION 3. 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 4. 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 5. (a) As soon as practicable after March 31,
2018, and to the extent appropriate based on the review conducted by
the Health and Human Services Commission under Section
531.024172(a), Government Code, as amended by this Act, the
commission shall implement an electronic visit verification system
that complies with Section 531.024172, Government Code, as amended
by this Act.
(b) As soon as practicable after the effective date of this
Act, 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 6. 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 7. This Act takes effect September 1, 2017.
______________________________ ______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 894 passed the Senate on
April 18, 2017, by the following vote: Yeas 31, Nays 0;
May 25, 2017, Senate refused to concur in House amendments and
requested appointment of Conference Committee; May 26, 2017, House
granted request of the Senate; May 28, 2017, Senate adopted
Conference Committee Report by the following vote: Yeas 29,
Nays 1.
______________________________
Secretary of the Senate
I hereby certify that S.B. No. 894 passed the House, with
amendments, on May 21, 2017, by the following vote: Yeas 142,
Nays 0, one present not voting; May 26, 2017, House granted request
of the Senate for appointment of Conference Committee;
May 28, 2017, House adopted Conference Committee Report by the
following vote: Yeas 141, Nays 0, one present not voting.
______________________________
Chief Clerk of the House
Approved:
______________________________
Date
______________________________
Governor