Relating to certain payment recovery and recoupment efforts under Medicaid and the child health plan program.
Impact
The proposed amendments aim to balance the need for cost recovery in Medicaid with the rights of healthcare providers. By codifying rules that require adequate notification and time for appeal before recoupment, the bill is intended to stabilize the financial interactions between managed care organizations and providers. Critics of rapid payment recoveries often argue that without such protections, providers may face undue pressure and financial strain, potentially leading to disruptions in care delivery.
Summary
House Bill 159 pertains to payment recovery and recoupment efforts related to Medicaid and the child health plan program in Texas. The bill mandates that the executive commissioner adopt rules that establish due process procedures for managed care organizations when they engage in payment recovery efforts. A core requirement is that these organizations must notify providers of their intent to recoup overpayments at least 60 days after providers have been allowed to appeal and cure any claim defects, thus offering some protection to healthcare providers against abrupt financial recoveries.
Contention
Notable points of contention arise over the limits placed on managed care organizations regarding the audit and review of claims. The bill explicitly prohibits organizations from reviewing medical necessity determinations or errors not attributable to the provider for previously approved claims. This provision seems designed to protect providers from retrospective scrutiny on matters they have already been authorized for, but it might also lead to concerns from managed care organizations about their ability to effectively manage costs and prevent fraud within the Medicaid system. These opposing interests paint a complex picture of healthcare regulation as it seeks to optimize both provider support and fiscal responsibility.
Texas Constitutional Statutes Affected
Government Code
Chapter 544. Fraud, Waste, Abuse, And Overcharges Relating To Health And Human Services
Relating to the nonsubstantive revision of the health and human services laws governing the Health and Human Services Commission, Medicaid, and other social services.
Relating to the retention by a managed care organization of certain money recovered as a result of a fraud or abuse investigation under Medicaid or the child health plan program.
Relating to the retention by a managed care organization of certain money recovered as a result of a fraud or abuse investigation under Medicaid or the child health plan program.