By: Buckingham, et al. S.B. No. 1991
(Klick)
A BILL TO BE ENTITLED
AN ACT
relating to claims and overpayment recoupment processes imposed on
health care providers under Medicaid.
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 Subsections (g-1) and (g-2)
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) If feasible, the executive commissioner shall ensure
a health care provider that uses the provider's proprietary
electronic visit verification system recognized under Subsection
(g) is reimbursed for the use of that system.
(g-2) For purposes of facilitating the use of proprietary
electronic visit verification systems by health care providers
under Subsection (g) and in consultation with industry stakeholders
and the work group established under Subsection (h), the commission
or the executive commissioner, as appropriate, shall:
(1) develop an open model system that mitigates the
administrative burdens identified by providers required to use
electronic visit verification;
(2) allow providers to use emerging technologies,
including Internet-based, mobile telephone-based, and global
positioning-based technologies, in the providers' proprietary
electronic visit verification systems; and
(3) adopt rules governing data submission and provider
reimbursement.
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 and
Section 531.1135 provide:
(1) written notice to a provider required to use
electronic visit verification of the organization's intent to
recoup overpayments in accordance with Section 531.1135; 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. The Health and Human Services Commission is
required to implement a provision of this Act only if the
legislature appropriates money to the commission specifically for
that purpose. If the legislature does not appropriate money
specifically for that purpose, the commission may, but is not
required to, implement a provision of this Act using other
appropriations that are available for that purpose.
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, 2019.