86R13429 KFF-F
By: Buckingham S.B. No. 1991
A BILL TO BE ENTITLED
AN ACT
relating to claims and overpayment recoupment processes imposed on
health care providers under Medicaid and other public benefits
programs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.024172, Government Code, is amended
by amending Subsection (g) and adding Subsection (g-1) to read as
follows:
(g) The commission may recognize a health care provider's
proprietary electronic visit verification system, whether
purchased or developed by the provider, 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; and
(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].
(g-1) The commission or a managed care organization shall
reimburse a health care provider providing services to a Medicaid
recipient at the same reimbursement rate for the same service
regardless of whether the provider uses the electronic visit
verification system implemented under Subsection (b) or the
provider's own proprietary electronic visit verification system
under Subsection (g).
SECTION 2. Section 531.1131, Government Code, is amended by
adding Subsection (f) to read as follows:
(f) In adopting rules establishing due process procedures
under Subsection (e), the executive commissioner shall require that
a managed care organization or an entity with which the managed care
organization contracts under Section 531.113(a)(2) that engages in
payment recovery efforts in accordance with this section provide:
(1) written notice to a provider of the organization's
intent to recoup overpayments; and
(2) a provider described by Subdivision (1) at least
60 days to cure any defect in a claim before the organization may
begin any efforts to collect overpayments.
SECTION 3. Subchapter C, Chapter 531, Government Code, is
amended by adding Section 531.1135 to read as follows:
Sec. 531.1135. MANAGED CARE ORGANIZATIONS: PROCESS TO
RECOUP CERTAIN OVERPAYMENTS. (a) The executive commissioner shall
adopt rules that standardize the process by which a managed care
organization collects alleged overpayments that are made to a
health care provider and discovered through an audit or
investigation conducted by the organization secondary to missing
electronic visit verification information. In adopting rules under
this section, the executive commissioner shall require that the
managed care organization:
(1) provide written notice of the organization's
intent to recoup overpayments not later than the 30th day after the
date an audit is complete; and
(2) limit the duration of audits to 24 months.
(b) The executive commissioner shall require that the
notice required under this section inform the provider:
(1) of the specific claims and electronic visit
verification transactions that are the basis of the overpayment;
(2) of the process the provider should use to
communicate with the managed care organization to provide
information about the electronic visit verification transactions;
(3) of the provider's option to seek an informal
resolution of the alleged overpayment;
(4) of the process to appeal the determination that an
overpayment was made; and
(5) if the provider intends to respond to the notice,
that the provider must respond not later than the 30th day after the
date the provider receives the notice.
(c) Notwithstanding any other law, a managed care
organization may not attempt to recover an overpayment described by
Subsection (a) until the provider has exhausted all rights to an
appeal.
SECTION 4. If before implementing any provision of this Act
a state agency determines that an additional waiver or additional
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 5. This Act takes effect September 1, 2019.