Texas 2019 - 86th Regular

Texas House Bill HB3157 Compare Versions

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

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1	1	By: Raymond H.B. No. 3157
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to the duties of the Health and Human Services
7	7	Commission's office of inspector general.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Section 531.001, Government Code, is amended by
10	10	adding Subdivision (4-c) to read as follows:
11	11	(4-c) "Medicaid managed care organization" means a
12	12	managed care organization as defined by Section 533.001 that
13	13	contracts with the commission under Chapter 533 to provide health
14	14	care services to Medicaid recipients.
15	15	SECTION 2. Section 531.102, Government Code, is amended by
16	16	amending Subsections (b), (f), (f-1), (h), (n), (p), and (r) and
17	17	adding Subsection (y) to read as follows:
18	18	(b) The [commission, in consultation with the] inspector
19	19	general[,] shall set clear objectives, priorities, and performance
20	20	standards for the office that emphasize:
21	21	(1) coordinating investigative efforts to
22	22	aggressively recover money;
23	23	(2) allocating resources to cases that have the
24	24	strongest supportive evidence [and the greatest potential for
25	25	recovery of money]; and
26	26	(3) maximizing opportunities for referral of cases to
27	27	the office of the attorney general in accordance with Section
28	28	531.103.
29	29	(f)(1) If the commission receives a complaint or allegation
30	30	of Medicaid fraud or abuse from any source, the office must conduct
31	31	a preliminary investigation as provided by Section 531.118(c) to
32	32	determine whether there is a sufficient basis to warrant a full
33	33	investigation. A preliminary investigation must begin not later
34	34	than the 30th day, and be completed not later than the 45th day,
35	35	after the date the commission receives a complaint or allegation or
36	36	has reason to believe that fraud or abuse has occurred.
37	37	(2) If the findings of a preliminary investigation
38	38	give the office reason to believe that an incident of fraud or abuse
39	39	involving possible criminal conduct has occurred in Medicaid, the
40	40	office must take the following action, as appropriate, not later
41	41	than the 30th day after the completion of the preliminary
42	42	investigation:
43	43	(A) if a provider or Medicaid managed care
44	44	organization is suspected of fraud or abuse involving criminal
45	45	conduct, the office must refer the case to the state's Medicaid
46	46	fraud control unit, provided that the criminal referral does not
47	47	preclude the office from continuing its investigation of the
48	48	provider or Medicaid managed care organization, which
49	49	investigation may lead to the imposition of appropriate
50	50	administrative or civil sanctions; or
51	51	(B) if there is reason to believe that a
52	52	recipient has defrauded Medicaid, the office may conduct a full
53	53	investigation of the suspected fraud, subject to Section
54	54	531.118(c).
55	55	(f-1) The office shall complete a full investigation of a
56	56	complaint or allegation of Medicaid fraud or abuse against a
57	57	provider or Medicaid managed care organization not later than the
58	58	180th day after the date the full investigation begins unless the
59	59	office determines that more time is needed to complete the
60	60	investigation. Except as otherwise provided by this subsection, if
61	61	the office determines that more time is needed to complete the
62	62	investigation, the office shall provide notice to the provider or
63	63	Medicaid managed care organization that [who] is the subject of the
64	64	investigation stating that the length of the investigation will
65	65	exceed 180 days and specifying the reasons why the office was unable
66	66	to complete the investigation within the 180-day period. The office
67	67	is not required to provide notice to the provider or Medicaid
68	68	managed care organization under this subsection if the office
69	69	determines that providing notice would jeopardize the
70	70	investigation.
71	71	(h) In addition to performing functions and duties
72	72	otherwise provided by law, the office may:
73	73	(1) assess administrative penalties otherwise
74	74	authorized by law on behalf of the commission or a health and human
75	75	services agency;
76	76	(2) request that the attorney general obtain an
77	77	injunction to prevent a person from disposing of an asset
78	78	identified by the office as potentially subject to recovery by the
79	79	office due to the person's fraud or abuse;
80	80	(3) provide for coordination between the office and
81	81	special investigative units formed by managed care organizations
82	82	under Section 531.113 or entities with which managed care
83	83	organizations contract under that section;
84	84	(4) audit the use and effectiveness of state or
85	85	federal funds, including contract and grant funds, administered by
86	86	a person, [or] state agency, or managed care organization receiving
87	87	the funds from a health and human services agency;
88	88	(5) conduct investigations relating to the funds
89	89	described by Subdivision (4); and
90	90	(6) recommend policies promoting economical and
91	91	efficient administration of the funds described by Subdivision (4)
92	92	and the prevention and detection of fraud and abuse in
93	93	administration of those funds.
94	94	(n) To the extent permitted under federal law, the executive
95	95	commissioner, on behalf of the office, shall adopt rules
96	96	establishing the criteria for initiating a full-scale fraud or
97	97	abuse investigation, conducting the investigation, collecting
98	98	evidence, accepting and approving a provider's request to post a
99	99	surety bond to secure potential recoupments in lieu of a payment
100	100	hold or other asset or payment guarantee, and establishing minimum
101	101	training requirements for Medicaid [provider] fraud or abuse
102	102	investigators.
103	103	(p) The executive commissioner, in consultation with the
104	104	office, shall adopt rules establishing criteria:
105	105	(1) for opening a case;
106	106	(2) for prioritizing cases for the efficient
107	107	management of the office's workload, including rules that direct
108	108	the office to prioritize:
109	109	(A) provider and managed care organization cases
110	110	according to the highest [potential for recovery or] risk to the
111	111	state [as indicated through the provider's volume of billings, the
112	112	provider's history of noncompliance with the law, and identified
113	113	fraud trends];
114	114	(B) recipient cases according to the highest
115	115	potential for recovery and federal timeliness requirements; and
116	116	(C) internal affairs investigations according to
117	117	the seriousness of the threat to recipient safety and the risk to
118	118	program integrity in terms of the amount or scope of fraud, waste,
119	119	and abuse posed by the allegation that is the subject of the
120	120	investigation; and
121	121	(3) to guide field investigators in closing a case
122	122	that is not worth pursuing through a full investigation.
123	123	(r) The office shall review the office's investigative
124	124	process, including the office's use of sampling and extrapolation
125	125	to audit provider and managed care organization records. The
126	126	review shall be performed by staff who are not directly involved in
127	127	investigations conducted by the office.
128	128	(y) Based on the results of an audit, inspection, or
129	129	investigation of a managed care organization conducted by the
130	130	office under this section, the office may recommend to the
131	131	commission that enforcement actions, including the payment of
132	132	liquidated damages, be taken against the managed care organization
133	133	and suggest the amount of a penalty to be assessed.
134	134	SECTION 3. Sections 531.102(g)(1) and (7), Government Code,
135	135	are amended to read as follows:
136	136	(1) Whenever the office learns or has reason to
137	137	suspect that a provider's or Medicaid managed care organization's
138	138	records are being withheld, concealed, destroyed, fabricated, or in
139	139	any way falsified, the office shall immediately refer the case to
140	140	the state's Medicaid fraud control unit.However, such criminal
141	141	referral does not preclude the office from continuing its
142	142	investigation of the provider or Medicaid managed care
143	143	organization, which investigation may lead to the imposition of
144	144	appropriate administrative or civil sanctions.
145	145	(7) The office shall, in consultation with the state's
146	146	Medicaid fraud control unit, establish guidelines under which
147	147	program exclusions:
148	148	(A) may permissively be imposed on a provider or
149	149	Medicaid managed care organization; or
150	150	(B) shall automatically be imposed on a provider
151	151	or Medicaid managed care organization.
152	152	SECTION 4. Sections 531.118(a) and (b), Government Code,
153	153	are amended to read as follows:
154	154	(a) The commission shall maintain a record of all
155	155	allegations of fraud or abuse against a provider or managed care
156	156	organization containing the date each allegation was received or
157	157	identified and the source of the allegation, if available. The
158	158	record is confidential under Section 531.1021(g) and is subject to
159	159	Section 531.1021(h).
160	160	(b) If the commission receives an allegation of fraud or
161	161	abuse against a provider or managed care organization from any
162	162	source, the commission's office of inspector general shall conduct
163	163	a preliminary investigation of the allegation to determine whether
164	164	there is a sufficient basis to warrant a full investigation. A
165	165	preliminary investigation must begin not later than the 30th day,
166	166	and be completed not later than the 45th day, after the date the
167	167	commission receives or identifies an allegation of fraud or abuse.
168	168	SECTION 5. Subchapter C, Chapter 531, Government Code, is
169	169	amended by adding Section 531.1185 to read as follows:
170	170	Sec. 531.1185. REVIEW, RENEGOTIATION, AND REVISION OF
171	171	CERTAIN FINAL ORDERS AND SETTLEMENT AGREEMENTS. The office of
172	172	inspector general may, on request by a provider, review,
173	173	renegotiate, and revise a final order or settlement agreement
174	174	currently under repayment entered into by the provider and the
175	175	office between January 1, 2011, and December 31, 2014. In
176	176	reviewing, renegotiating, and revising a final order or settlement
177	177	agreement under this section, the office shall consider:
178	178	(1) amounts paid by the provider under the order or
179	179	agreement;
180	180	(2) amounts paid or lost by the provider as a result of
181	181	any investigation, audit, or inspection that was the basis of the
182	182	order or agreement; and
183	183	(3) amounts of federal share paid.
184	184	SECTION 6. Subchapter A, Chapter 533, Government Code, is
185	185	amended by adding Section 533.0122 to read as follows:
186	186	Sec. 533.0122. UTILIZATION REVIEW AUDITS CONDUCTED BY
187	187	OFFICE OF INSPECTOR GENERAL. (a) If the commission's office of
188	188	inspector general intends to conduct a utilization review audit of
189	189	a provider of services under a Medicaid managed care delivery
190	190	model, the office shall inform both the provider and the Medicaid
191	191	managed care organization with which the provider contracts of any
192	192	applicable criteria and guidelines the office will use in the
193	193	course of the audit.
194	194	(b) The commission's office of inspector general shall
195	195	ensure that each person conducting a utilization review audit under
196	196	this section has experience and training regarding the operations
197	197	of Medicaid managed care organizations.
198	198	(c) The commission's office of inspector general may not, as
199	199	the result of a utilization review audit, recoup an overpayment or
200	200	debt from a provider that contracts with a Medicaid managed care
201	201	organization based on a determination that a provided service was
202	202	not medically necessary unless the office:
203	203	(1) uses the same criteria and guidelines that were
204	204	used by the managed care organization in its determination of
205	205	medical necessity for the service; and
206	206	(2) verifies with the managed care organization and
207	207	the provider that the provider:
208	208	(A) at the time the service was delivered, had
209	209	reasonable notice of the criteria and guidelines used by the
210	210	managed care organization to determine medical necessity; and
211	211	(B) did not follow the criteria and guidelines
212	212	used by the managed care organization to determine medical
213	213	necessity that were in effect at the time the service was delivered.
214	214	SECTION 7. Not later than December 31, 2019, the executive
215	215	commissioner of the Health and Human Services Commission shall
216	216	adopt rules necessary to implement the changes in law made by this
217	217	Act.
218	218	SECTION 8. If before implementing any provision of this Act
219	219	a state agency determines that a waiver or authorization from a
220	220	federal agency is necessary for implementation of that provision,
221	221	the agency affected by the provision shall request the waiver or
222	222	authorization and may delay implementing that provision until the
223	223	waiver or authorization is granted.
224	224	SECTION 9. This Act takes effect September 1, 2019.