Texas 2021 - 87th Regular

Texas House Bill HB648 Compare Versions

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

Old	New	Differences
1	1	87R593 JG-F
2	2	By: Raymond H.B. No. 648
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the duties of the Health and Human Services
8	8	Commission's office of inspector general.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 531.102, Government Code, is amended by
11	11	amending Subsections (b), (f), (f-1), (h), (n), (p), and (r) and
12	12	adding Subsection (z) to read as follows:
13	13	(b) The [commission, in consultation with the] inspector
14	14	general[,] shall set clear objectives, priorities, and performance
15	15	standards for the office that emphasize:
16	16	(1) coordinating investigative efforts to
17	17	aggressively recover money;
18	18	(2) allocating resources to cases that have the
19	19	strongest supportive evidence [and the greatest potential for
20	20	recovery of money]; and
21	21	(3) maximizing opportunities for referral of cases to
22	22	the office of the attorney general in accordance with Section
23	23	531.103.
24	24	(f)(1) If the commission receives a complaint or allegation
25	25	of Medicaid fraud or abuse from any source, the office must conduct
26	26	a preliminary investigation as provided by Section 531.118(c) to
27	27	determine whether there is a sufficient basis to warrant a full
28	28	investigation. A preliminary investigation must begin not later
29	29	than the 30th day, and be completed not later than the 45th day,
30	30	after the date the commission receives a complaint or allegation or
31	31	has reason to believe that fraud or abuse has occurred.
32	32	(2) If the findings of a preliminary investigation
33	33	give the office reason to believe that an incident of fraud or abuse
34	34	involving possible criminal conduct has occurred in Medicaid, the
35	35	office must take the following action, as appropriate, not later
36	36	than the 30th day after the completion of the preliminary
37	37	investigation:
38	38	(A) if a provider or Medicaid managed care
39	39	organization is suspected of fraud or abuse involving criminal
40	40	conduct, the office must refer the case to the state's Medicaid
41	41	fraud control unit, provided that the criminal referral does not
42	42	preclude the office from continuing its investigation of the
43	43	provider or Medicaid managed care organization, which
44	44	investigation may lead to the imposition of appropriate
45	45	administrative or civil sanctions; or
46	46	(B) if there is reason to believe that a
47	47	recipient has defrauded Medicaid, the office may conduct a full
48	48	investigation of the suspected fraud[, subject to Section
49	49	531.118(c)].
50	50	(f-1) The office shall complete a full investigation of a
51	51	complaint or allegation of Medicaid fraud or abuse against a
52	52	provider or Medicaid managed care organization not later than the
53	53	180th day after the date the full investigation begins unless the
54	54	office determines that more time is needed to complete the
55	55	investigation. Except as otherwise provided by this subsection,
56	56	if the office determines that more time is needed to complete the
57	57	investigation, the office shall provide notice to the provider or
58	58	Medicaid managed care organization that [who] is the subject of the
59	59	investigation stating that the length of the investigation will
60	60	exceed 180 days and specifying the reasons why the office was unable
61	61	to complete the investigation within the 180-day period. The
62	62	office is not required to provide notice to the provider or Medicaid
63	63	managed care organization under this subsection if the office
64	64	determines that providing notice would jeopardize the
65	65	investigation.
66	66	(h) In addition to performing functions and duties
67	67	otherwise provided by law, the office may:
68	68	(1) assess administrative penalties otherwise
69	69	authorized by law on behalf of the commission or a health and human
70	70	services agency;
71	71	(2) request that the attorney general obtain an
72	72	injunction to prevent a person from disposing of an asset
73	73	identified by the office as potentially subject to recovery by the
74	74	office due to the person's fraud or abuse;
75	75	(3) provide for coordination between the office and
76	76	special investigative units formed by managed care organizations
77	77	under Section 531.113 or entities with which managed care
78	78	organizations contract under that section;
79	79	(4) audit the use and effectiveness of state or
80	80	federal funds, including contract and grant funds, administered by
81	81	a person, [or] state agency, or managed care organization receiving
82	82	the funds from a health and human services agency;
83	83	(5) conduct investigations relating to the funds
84	84	described by Subdivision (4); and
85	85	(6) recommend policies promoting economical and
86	86	efficient administration of the funds described by Subdivision (4)
87	87	and the prevention and detection of fraud and abuse in
88	88	administration of those funds.
89	89	(n) To the extent permitted under federal law, the executive
90	90	commissioner, on behalf of the office, shall adopt rules
91	91	establishing the criteria for initiating a full-scale fraud or
92	92	abuse investigation, conducting the investigation, collecting
93	93	evidence, accepting and approving a provider's request to post a
94	94	surety bond to secure potential recoupments in lieu of a payment
95	95	hold or other asset or payment guarantee, and establishing minimum
96	96	training requirements for Medicaid [provider] fraud or abuse
97	97	investigators.
98	98	(p) The executive commissioner, in consultation with the
99	99	office, shall adopt rules establishing criteria:
100	100	(1) for opening a case;
101	101	(2) for prioritizing cases for the efficient
102	102	management of the office's workload, including rules that direct
103	103	the office to prioritize:
104	104	(A) provider and managed care organization cases
105	105	according to the highest [potential for recovery or] risk to the
106	106	state [as indicated through the provider's volume of billings, the
107	107	provider's history of noncompliance with the law, and identified
108	108	fraud trends];
109	109	(B) recipient cases according to the highest
110	110	potential for recovery and federal timeliness requirements; and
111	111	(C) internal affairs investigations according to
112	112	the seriousness of the threat to recipient safety and the risk to
113	113	program integrity in terms of the amount or scope of fraud, waste,
114	114	and abuse posed by the allegation that is the subject of the
115	115	investigation; and
116	116	(3) to guide field investigators in closing a case
117	117	that is not worth pursuing through a full investigation.
118	118	(r) The office shall review the office's investigative
119	119	process, including the office's use of sampling and extrapolation
120	120	to audit provider and managed care organization records. The
121	121	review shall be performed by staff who are not directly involved in
122	122	investigations conducted by the office.
123	123	(z) Based on the results of an audit, inspection, or
124	124	investigation of a managed care organization conducted by the
125	125	office under this section, the office may recommend to the
126	126	commission that enforcement actions, including the payment of
127	127	liquidated damages, be taken against the managed care organization
128	128	and suggest the amount of a penalty to be assessed.
129	129	SECTION 2. Sections 531.102(g)(1) and (7), Government Code,
130	130	are amended to read as follows:
131	131	(1) Whenever the office learns or has reason to
132	132	suspect that a provider's or Medicaid managed care organization's
133	133	records are being withheld, concealed, destroyed, fabricated, or in
134	134	any way falsified, the office shall immediately refer the case to
135	135	the state's Medicaid fraud control unit. However, such criminal
136	136	referral does not preclude the office from continuing its
137	137	investigation of the provider or Medicaid managed care
138	138	organization, which investigation may lead to the imposition of
139	139	appropriate administrative or civil sanctions.
140	140	(7) The office shall, in consultation with the state's
141	141	Medicaid fraud control unit, establish guidelines under which
142	142	program exclusions:
143	143	(A) may permissively be imposed on a provider or
144	144	Medicaid managed care organization; or
145	145	(B) shall automatically be imposed on a provider
146	146	or Medicaid managed care organization.
147	147	SECTION 3. Sections 531.118(a) and (b), Government Code,
148	148	are amended to read as follows:
149	149	(a) The commission shall maintain a record of all
150	150	allegations of fraud or abuse against a provider or managed care
151	151	organization containing the date each allegation was received or
152	152	identified and the source of the allegation, if available. The
153	153	record is confidential under Section 531.1021(g) and is subject to
154	154	Section 531.1021(h).
155	155	(b) If the commission receives an allegation of fraud or
156	156	abuse against a provider or managed care organization from any
157	157	source, the commission's office of inspector general shall conduct
158	158	a preliminary investigation of the allegation to determine whether
159	159	there is a sufficient basis to warrant a full investigation. A
160	160	preliminary investigation must begin not later than the 30th day,
161	161	and be completed not later than the 45th day, after the date the
162	162	commission receives or identifies an allegation of fraud or abuse.
163	163	SECTION 4. Subchapter C, Chapter 531, Government Code, is
164	164	amended by adding Section 531.1185 to read as follows:
165	165	Sec. 531.1185. REVIEW, RENEGOTIATION, AND REVISION OF
166	166	CERTAIN FINAL ORDERS AND SETTLEMENT AGREEMENTS. The office of
167	167	inspector general may, on request by a provider, review,
168	168	renegotiate, and revise a final order or settlement agreement
169	169	currently under repayment entered into by the provider and the
170	170	office between January 1, 2011, and December 31, 2014. In
171	171	reviewing, renegotiating, and revising a final order or settlement
172	172	agreement under this section, the office shall consider:
173	173	(1) amounts being paid by the provider under the order
174	174	or agreement;
175	175	(2) amounts paid or lost by the provider as a result of
176	176	any investigation, audit, or inspection that was the basis of the
177	177	order or agreement; and
178	178	(3) amounts of the federal share paid or being paid.
179	179	SECTION 5. Subchapter A, Chapter 533, Government Code, is
180	180	amended by adding Section 533.0122 to read as follows:
181	181	Sec. 533.0122. UTILIZATION REVIEW AUDITS CONDUCTED BY
182	182	OFFICE OF INSPECTOR GENERAL. (a) If the commission's office of
183	183	inspector general intends to conduct a utilization review audit of
184	184	a provider of services under a Medicaid managed care delivery
185	185	model, the office shall inform both the provider and the Medicaid
186	186	managed care organization with which the provider contracts of any
187	187	applicable criteria and guidelines the office will use in the
188	188	course of the audit.
189	189	(b) The commission's office of inspector general shall
190	190	ensure that each person conducting a utilization review audit under
191	191	this section has experience and training regarding the operations
192	192	of Medicaid managed care organizations.
193	193	(c) The commission's office of inspector general may not, as
194	194	the result of a utilization review audit, recoup an overpayment or
195	195	debt from a provider that contracts with a Medicaid managed care
196	196	organization based on a determination that a provided service was
197	197	not medically necessary unless the office:
198	198	(1) uses the same criteria and guidelines that were
199	199	used by the managed care organization in its determination of
200	200	medical necessity for the service; and
201	201	(2) verifies with the managed care organization and
202	202	the provider that the provider:
203	203	(A) at the time the service was delivered, had
204	204	reasonable notice of the criteria and guidelines used by the
205	205	managed care organization to determine medical necessity; and
206	206	(B) did not follow the criteria and guidelines
207	207	used by the managed care organization to determine medical
208	208	necessity that were in effect at the time the service was delivered.
209	209	SECTION 6. Not later than December 31, 2021, the executive
210	210	commissioner of the Health and Human Services Commission shall
211	211	adopt rules necessary to implement the changes in law made by this
212	212	Act.
213	213	SECTION 7. If before implementing any provision of this Act
214	214	a state agency determines that a waiver or authorization from a
215	215	federal agency is necessary for implementation of that provision,
216	216	the agency affected by the provision shall request the waiver or
217	217	authorization and may delay implementing that provision until the
218	218	waiver or authorization is granted.
219	219	SECTION 8. This Act takes effect September 1, 2021.