86R9790 JG-D
By: Hinojosa S.B. No. 1483
A BILL TO BE ENTITLED
AN ACT
relating to the proof required to impose payment holds in certain
cases of alleged fraud by Medicaid providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Sections 531.102(g)(2) and (3), Government Code,
are amended to read as follows:
(2) As authorized under state and federal law, and
except as provided by Subdivisions (8) and (9), the office shall
impose without prior notice a payment hold on claims for
reimbursement submitted by a provider only to compel production of
records, when requested by the state's Medicaid fraud control unit,
or on the determination by the office that a credible allegation of
fraud exists, subject to Subsections (l) and (m), as applicable.
The payment hold is a serious enforcement tool that the office
imposes to mitigate ongoing financial risk to the state. A payment
hold imposed under this subdivision takes effect immediately. The
office must notify the provider of the payment hold in accordance
with 42 C.F.R. Section 455.23(b) and, except as provided by that
regulation, not later than the fifth day after the date the office
imposes the payment hold. In addition to the requirements of 42
C.F.R. Section 455.23(b), the notice of payment hold provided under
this subdivision must also include:
(A) the specific basis for the hold, including
identification of the claims supporting the allegation at that
point in the investigation, a representative sample of any
documents that form the basis for the hold, and a detailed summary
of the office's evidence relating to the allegation;
(B) a description of administrative and judicial
due process rights and remedies, including the provider's option to
seek informal resolution, the provider's right to seek a formal
administrative appeal hearing, or that the provider may seek both;
and
(C) a detailed timeline for the provider to
pursue the rights and remedies described in Paragraph (B).
(3) On timely written request by a provider subject to
a payment hold under Subdivision (2), other than a hold requested by
the state's Medicaid fraud control unit, the office shall file a
request with the State Office of Administrative Hearings for an
expedited administrative hearing regarding the hold not later than
the third day after the date the office receives the provider's
request. The provider must request an expedited administrative
hearing under this subdivision not later than the 10th day after the
date the provider receives notice from the office under Subdivision
(2). The State Office of Administrative Hearings shall hold the
expedited administrative hearing not later than the 45th day after
the date the State Office of Administrative Hearings receives the
request for the hearing. In a hearing held under this subdivision:
(A) the provider and the office are each limited
to four hours of testimony, excluding time for responding to
questions from the administrative law judge;
(B) the provider and the office are each entitled
to two continuances under reasonable circumstances; and
(C) the office is required to show probable cause
that the credible allegation of fraud that is the basis of the
payment hold has an indicia of reliability and that continuing to
pay the provider presents [an ongoing significant financial risk to
the state and] a threat to the integrity of Medicaid due to:
(i) an ongoing significant financial risk
to the state that may result in the loss of $100,000 or more; or
(ii) a high probability that a serious
threat to the health or safety of a recipient exists or may develop
as a result of the provider's conduct.
SECTION 2. 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 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2019.