89R23116 CMO-D
By: Oliverson H.B. No. 3984
Substitute the following for H.B. No. 3984:
By: Hull C.S.H.B. No. 3984
A BILL TO BE ENTITLED
AN ACT
relating to the review of claims and recovery of overpayments by
Medicaid recovery audit contractors.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 544.0504, Government Code, is amended to
read as follows:
Sec. 544.0504. RECOVERY AUDIT CONTRACTORS. (a) To the
extent required under Section 1902(a)(42), Social Security Act (42
U.S.C. Section 1396a(a)(42)), the commission shall establish a
program under which the commission contracts with one or more
recovery audit contractors to:
(1) identify Medicaid underpayments and overpayments,
including underpayments and overpayments under the Medicaid
managed care program; and
(2) recover the overpayments.
(b) An overpayment under Subsection (a)(2) may be recovered
from either the provider or the managed care organization.
(c) A recovery audit contractor may not:
(1) initiate a review of a claim unless:
(A) the office of inspector general or the
office's designee:
(i) determines that the review would be
cost-effective; and
(ii) approves the review; and
(B) at least one year has elapsed since the date
the claim was received; or
(2) initiate a recovery effort on a claim if a managed
care organization has notified the office of inspector general that
the organization is auditing the claim.
(d) On request by a recovery audit contractor or the office
of inspector general, a managed care organization or provider who
is the subject of a review conducted under this section shall submit
to the contractor or office all information necessary to perform
the review not later than the date specified in the request. All
information and materials obtained under this section are
confidential under Section 544.0259(e).
(e) The executive commissioner by rule shall adopt a process
for appeals related to overpayments identified by a recovery audit
contractor under this section.
(f) The commission may contract with a third party to
administer Subsection (b) or the appeals process adopted under
Subsection (e).
(g) The executive commissioner, in consultation with the
office of inspector general, may adopt rules necessary to implement
this section.
SECTION 2. 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 3. The Health and Human Services Commission is
required to implement the changes in law made by this Act to Section
544.0504, Government Code, only if the legislature appropriates
money specifically for that purpose. If the legislature does not
appropriate money specifically for that purpose, the commission
may, but is not required to, implement those changes in law using
other money available to the commission for that purpose.
SECTION 4. This Act takes effect September 1, 2025.