Texas 2023 - 88th Regular

Texas House Bill HB3779 Compare Versions

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1	1	88R3702 SCP-D
2	2	By: Noble H.B. No. 3779
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to fraud prevention under certain health care programs.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Article 39.026(a)(3), Code of Criminal
10	10	Procedure, is amended to read as follows:
11	11	(3) "Medicaid recipient" means an individual on whose
12	12	behalf a person claims or receives a payment from the Medicaid
13	13	program or a fiscal agent, without regard to whether the individual
14	14	was eligible for benefits under the Medicaid program [has the
15	15	meaning assigned by Section 36.001, Human Resources Code].
16	16	SECTION 2. The heading to Chapter 36, Human Resources Code,
17	17	is amended to read as follows:
18	18	CHAPTER 36. HEALTH CARE PROGRAM [MEDICAID] FRAUD PREVENTION
19	19	SECTION 3. Section 36.001, Human Resources Code, is amended
20	20	by amending Subdivisions (1), (2), (3), (5), (9), and (10) and
21	21	adding Subdivisions (4-a) and (4-b) to read as follows:
22	22	(1) "Claim" means a written or electronically
23	23	submitted request or demand that:
24	24	(A) is signed by a provider or a fiscal agent and
25	25	that identifies a product or service provided or purported to have
26	26	been provided to a health care [Medicaid] recipient as reimbursable
27	27	under a health care [the Medicaid] program, without regard to
28	28	whether the money that is requested or demanded is paid; or
29	29	(B) states the income earned or expense incurred
30	30	by a provider in providing a product or a service and that is used to
31	31	determine a rate of payment under a health care [the Medicaid]
32	32	program.
33	33	(2) "Documentary material" means a record, document,
34	34	or other tangible item of any form, including:
35	35	(A) a medical document or X ray prepared by a
36	36	person in relation to the provision or purported provision of a
37	37	product or service to a health care [Medicaid] recipient;
38	38	(B) a medical, professional, or business record
39	39	relating to:
40	40	(i) the provision of a product or service to
41	41	a health care [Medicaid] recipient; or
42	42	(ii) a rate or amount paid or claimed for a
43	43	product or service, including a record relating to a product or
44	44	service provided to a person other than a health care [Medicaid]
45	45	recipient as needed to verify the rate or amount;
46	46	(C) a record required to be kept by an agency that
47	47	regulates health care providers; or
48	48	(D) a record necessary to disclose the extent of
49	49	services a provider furnishes to health care [Medicaid] recipients.
50	50	(3) "Fiscal agent" means:
51	51	(A) a person who, through a contractual
52	52	relationship with a state agency, receives, processes, and pays a
53	53	claim under a health care [the Medicaid] program; or
54	54	(B) the designated agent of a person described by
55	55	Paragraph (A).
56	56	(4-a) "Health care program" has the meaning assigned
57	57	by Section 35A.01, Penal Code.
58	58	(4-b) "Health care recipient" means an individual on
59	59	whose behalf a person claims or receives a payment from a health
60	60	care program or a fiscal agent, without regard to whether the
61	61	individual was eligible for benefits under the health care program.
62	62	(5) "Managed care organization" means a person who is
63	63	authorized or otherwise permitted by law to arrange for or provide a
64	64	managed care plan [has the meaning assigned by Section 32.039(a)].
65	65	(9) "Provider" means a person who participates in or
66	66	who has applied to participate in a health care [the Medicaid]
67	67	program as a supplier of a product or service and includes:
68	68	(A) a management company that manages, operates,
69	69	or controls another provider;
70	70	(B) a person, including a medical vendor, that
71	71	provides a product or service to a provider or to a fiscal agent;
72	72	(C) an employee of a provider;
73	73	(D) a managed care organization; and
74	74	(E) a manufacturer or distributor of a product
75	75	for which a health care [the Medicaid] program provides
76	76	reimbursement.
77	77	(10) "Service" includes care or treatment of a health
78	78	care [Medicaid] recipient.
79	79	SECTION 4. Section 36.002, Human Resources Code, is amended
80	80	to read as follows:
81	81	Sec. 36.002. UNLAWFUL ACTS. A person commits an unlawful
82	82	act if the person:
83	83	(1) knowingly makes or causes to be made a false
84	84	statement or misrepresentation of a material fact to permit a
85	85	person to receive a benefit or payment under a health care [the
86	86	Medicaid] program that is not authorized or that is greater than the
87	87	benefit or payment that is authorized;
88	88	(2) knowingly conceals or fails to disclose
89	89	information that permits a person to receive a benefit or payment
90	90	under a health care [the Medicaid] program that is not authorized or
91	91	that is greater than the benefit or payment that is authorized;
92	92	(3) knowingly applies for and receives a benefit or
93	93	payment on behalf of another person under a health care [the
94	94	Medicaid] program and converts any part of the benefit or payment to
95	95	a use other than for the benefit of the person on whose behalf it was
96	96	received;
97	97	(4) knowingly makes, causes to be made, induces, or
98	98	seeks to induce the making of a false statement or
99	99	misrepresentation of material fact concerning:
100	100	(A) the conditions or operation of a facility in
101	101	order that the facility may qualify for certification or
102	102	recertification required by a health care [the Medicaid] program,
103	103	including certification or recertification as:
104	104	(i) a hospital;
105	105	(ii) a nursing facility or skilled nursing
106	106	facility;
107	107	(iii) a hospice;
108	108	(iv) an ICF-IID;
109	109	(v) an assisted living facility; or
110	110	(vi) a home health agency; or
111	111	(B) information required to be provided by a
112	112	federal or state law, rule, regulation, or provider agreement
113	113	pertaining to a health care [the Medicaid] program;
114	114	(5) except as authorized under a health care [the
115	115	Medicaid] program, knowingly pays, charges, solicits, accepts, or
116	116	receives, in addition to an amount paid under the [Medicaid]
117	117	program, a gift, money, a donation, or other consideration as a
118	118	condition to the provision of a service or product or the continued
119	119	provision of a service or product if the cost of the service or
120	120	product is paid for, in whole or in part, under the [Medicaid]
121	121	program;
122	122	(6) knowingly presents or causes to be presented a
123	123	claim for payment under a health care [the Medicaid] program for a
124	124	product provided or a service rendered by a person who:
125	125	(A) is not licensed to provide the product or
126	126	render the service, if a license is required; or
127	127	(B) is not licensed in the manner claimed;
128	128	(7) knowingly makes or causes to be made a claim under
129	129	a health care [the Medicaid] program for:
130	130	(A) a service or product that has not been
131	131	approved or acquiesced in by a treating physician or health care
132	132	practitioner;
133	133	(B) a service or product that is substantially
134	134	inadequate or inappropriate when compared to generally recognized
135	135	standards within the particular discipline or within the health
136	136	care industry; or
137	137	(C) a product that has been adulterated, debased,
138	138	mislabeled, or that is otherwise inappropriate;
139	139	(8) makes a claim under a health care [the Medicaid]
140	140	program and knowingly fails to indicate the type of license and the
141	141	identification number of the licensed health care provider who
142	142	actually provided the service;
143	143	(9) conspires to commit a violation of Subdivision
144	144	(1), (2), (3), (4), (5), (6), (7), (8), (10), (11), (12), or (13);
145	145	(10) is a managed care organization that contracts
146	146	with the commission or other state agency to provide or arrange to
147	147	provide health care benefits or services to individuals eligible
148	148	under a health care [the Medicaid] program and knowingly:
149	149	(A) fails to provide to an individual a health
150	150	care benefit or service that the organization is required to
151	151	provide under the contract;
152	152	(B) fails to provide to the commission or
153	153	appropriate state agency information required to be provided by
154	154	law, commission or agency rule, or contractual provision; or
155	155	(C) engages in a fraudulent activity in
156	156	connection with the enrollment of an individual eligible under the
157	157	[Medicaid] program in the organization's managed care plan or in
158	158	connection with marketing the organization's services to an
159	159	individual eligible under the [Medicaid] program;
160	160	(11) knowingly obstructs an investigation by the
161	161	attorney general of an alleged unlawful act under this section;
162	162	(12) knowingly makes, uses, or causes the making or
163	163	use of a false record or statement material to an obligation to pay
164	164	or transmit money or property to this state under a health care [the
165	165	Medicaid] program, or knowingly conceals or knowingly and
166	166	improperly avoids or decreases an obligation to pay or transmit
167	167	money or property to this state under a health care [the Medicaid]
168	168	program; [or]
169	169	(13) knowingly engages in conduct that constitutes a
170	170	violation under Section 32.039(b); or
171	171	(14) otherwise engages in conduct that constitutes an
172	172	offense under Section 35A.02(a), Penal Code.
173	173	SECTION 5. Section 36.003(a), Human Resources Code, is
174	174	amended to read as follows:
175	175	(a) A state agency, including the commission, the
176	176	Department of State Health Services, the Department of Aging and
177	177	Disability Services, and the Department of Family and Protective
178	178	Services, shall provide the attorney general access to all
179	179	documentary materials of persons and health care [Medicaid]
180	180	recipients under a health care [the Medicaid] program to which that
181	181	agency has access. Documentary material provided under this
182	182	subsection is provided to permit investigation of an alleged
183	183	unlawful act or for use or potential use in an administrative or
184	184	judicial proceeding.
185	185	SECTION 6. Section 36.005(b), Human Resources Code, is
186	186	amended to read as follows:
187	187	(b) A provider found liable under Section 36.052 for an
188	188	unlawful act may not, for a period of 10 years, provide or arrange
189	189	to provide health care services under a health care [the Medicaid]
190	190	program or supply or sell, directly or indirectly, a product to or
191	191	under a health care [the Medicaid] program. The executive
192	192	commissioner may by rule:
193	193	(1) provide for a period of ineligibility longer than
194	194	10 years; or
195	195	(2) grant a provider a full or partial exemption from
196	196	the period of ineligibility required by this subsection if the
197	197	executive commissioner finds that enforcement of the full period of
198	198	ineligibility is harmful to the [Medicaid] program or a beneficiary
199	199	of the program.
200	200	SECTION 7. Section 36.008, Human Resources Code, is amended
201	201	to read as follows:
202	202	Sec. 36.008. USE OF MONEY RECOVERED. The legislature, in
203	203	appropriating money recovered under this chapter, shall consider
204	204	the requirements of the attorney general and other affected state
205	205	agencies in investigating health care program [Medicaid] fraud and
206	206	enforcing this chapter.
207	207	SECTION 8. Section 36.052(a), Human Resources Code, is
208	208	amended to read as follows:
209	209	(a) Except as provided by Subsection (c), a person who
210	210	commits an unlawful act is liable to the state for:
211	211	(1) the amount of any payment or the value of any
212	212	monetary or in-kind benefit provided under a health care [the
213	213	Medicaid] program, directly or indirectly, as a result of the
214	214	unlawful act, including any payment made to a third party;
215	215	(2) interest on the amount of the payment or the value
216	216	of the benefit described by Subdivision (1) at the prejudgment
217	217	interest rate in effect on the day the payment or benefit was
218	218	received or paid, for the period from the date the benefit was
219	219	received or paid to the date that the state recovers the amount of
220	220	the payment or value of the benefit;
221	221	(3) a civil penalty of:
222	222	(A) not less than $5,500 or the minimum amount
223	223	imposed as provided by 31 U.S.C. Section 3729(a), if that amount
224	224	exceeds $5,500, and not more than $15,000 or the maximum amount
225	225	imposed as provided by 31 U.S.C. Section 3729(a), if that amount
226	226	exceeds $15,000, for each unlawful act committed by the person that
227	227	results in injury to an elderly person, as defined by Section
228	228	48.002(a)(1), a person with a disability, as defined by Section
229	229	48.002(a)(8)(A), or a person younger than 18 years of age; or
230	230	(B) not less than $5,500 or the minimum amount
231	231	imposed as provided by 31 U.S.C. Section 3729(a), if that amount
232	232	exceeds $5,500, and not more than $11,000 or the maximum amount
233	233	imposed as provided by 31 U.S.C. Section 3729(a), if that amount
234	234	exceeds $11,000, for each unlawful act committed by the person that
235	235	does not result in injury to a person described by Paragraph (A);
236	236	and
237	237	(4) two times the amount of the payment or the value of
238	238	the benefit described by Subdivision (1).
239	239	SECTION 9. Section 36.054(h), Human Resources Code, is
240	240	amended to read as follows:
241	241	(h) A person who has committed an unlawful act in relation
242	242	to a health care [the Medicaid] program in this state has submitted
243	243	to the jurisdiction of this state and personal service of an
244	244	investigative demand under this section may be made on the person
245	245	outside of this state.
246	246	SECTION 10. Section 36.055, Human Resources Code, is
247	247	amended to read as follows:
248	248	Sec. 36.055. ATTORNEY GENERAL AS RELATOR IN FEDERAL ACTION.
249	249	To the extent permitted by 31 U.S.C. Sections 3729-3733, the
250	250	attorney general may bring an action as relator under 31 U.S.C.
251	251	Section 3730 with respect to an act in connection with a health care
252	252	[the Medicaid] program for which a person may be held liable under
253	253	31 U.S.C. Section 3729. The attorney general may contract with a
254	254	private attorney to represent the state under this section.
255	255	SECTION 11. Section 36.132(a)(2), Human Resources Code, is
256	256	amended to read as follows:
257	257	(2) "Licensing authority" means:
258	258	(A) the Texas Medical Board;
259	259	(B) the State Board of Dental Examiners;
260	260	(C) the Texas Behavioral Health Executive
261	261	Council;
262	262	(D) the Texas Board of Nursing;
263	263	(E) the Texas Board of Physical Therapy
264	264	Examiners;
265	265	(F) the Texas Board of Occupational Therapy
266	266	Examiners; or
267	267	(G) another state agency authorized to regulate a
268	268	provider who receives or is eligible to receive payment for a health
269	269	care service under a health care [the Medicaid] program.
270	270	SECTION 12. Sections 36.001(6) and (7), Human Resources
271	271	Code, are repealed.
272	272	SECTION 13. The changes in law made by this Act apply only
273	273	to an unlawful act described by Section 36.002, Human Resources
274	274	Code, as amended by this Act, that is committed on or after the
275	275	effective date of this Act.
276	276	SECTION 14. If before implementing any provision of this
277	277	Act a state agency determines that a waiver or authorization from a
278	278	federal agency is necessary for implementation of that provision,
279	279	the agency affected by the provision shall request the waiver or
280	280	authorization and may delay implementing that provision until the
281	281	waiver or authorization is granted.
282	282	SECTION 15. This Act takes effect September 1, 2023.