Bill Text: TX HB3917 | 2015-2016 | 84th Legislature | Comm Sub
Bill Title: Relating to the recoupment of payments on certain provider claims made under the Medicaid program.
Spectrum: Moderate Partisan Bill (Republican 4-1)
Status: (Introduced - Dead) 2015-05-05 - Committee report sent to Calendars [HB3917 Detail]
Download: Texas-2015-HB3917-Comm_Sub.html
84R25644 JSL-F | |||
By: Klick, et al. | H.B. No. 3917 | ||
Substitute the following for H.B. No. 3917: | |||
By: Raymond | C.S.H.B. No. 3917 |
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relating to the recoupment of payments on certain provider claims | ||
made under the Medicaid program. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter B, Chapter 32, Human Resources Code, | ||
is amended by adding Sections 32.0631 and 32.0632 to read as | ||
follows: | ||
Sec. 32.0631. POLICIES RELATED TO RECOUPMENT OF PAYMENTS. | ||
(a) Notwithstanding any other law the commission shall, subject to | ||
Subsection (b), develop and implement policies to prevent | ||
recoupment of an improper payment that was made to a provider for a | ||
claim for medical services made under the medical assistance | ||
program if the provider: | ||
(1) actually provided a medical service reimbursable | ||
under the medical assistance program; and | ||
(2) submitted a clean claim as required under the | ||
medical assistance program. | ||
(b) The policies developed under Subsection (a) must: | ||
(1) allow the recoupment of an improper payment in the | ||
case of fraud or abuse; and | ||
(2) require that when recoupment is allowed, the | ||
amount of a recouped payment may be no greater than the difference | ||
between the payment amount made to the provider that is subject to | ||
recoupment and the reimbursement rate in effect on the date the | ||
service was provided. | ||
(c) To reduce the incidence of improper payments under the | ||
medical assistance program, the commission shall develop and | ||
implement methods to improve communication between: | ||
(1) the commission; | ||
(2) providers under the program; | ||
(3) entities with which the commission contracts to | ||
administer claims under the program; and | ||
(4) managed care organizations with which the | ||
commission contracts to provide medical services to recipients | ||
under the program. | ||
(d) The methods to improve communication under Subsection | ||
(c) must include requirements to provide necessary information to a | ||
provider regarding: | ||
(1) how, and to whom, the provider must submit a clean | ||
claim; and | ||
(2) how the provider may file a complaint with the | ||
commission regarding a payment dispute, including a complaint that | ||
may be filed after the provider has exhausted all rights to appeal. | ||
Sec. 32.0632. PROCESSES AND IMPROVEMENTS RELATED TO | ||
OVERPAYMENT OF CLAIMS. (a) The commission shall conduct separate | ||
studies to: | ||
(1) evaluate the feasibility of implementing a process | ||
that allows an entity with which the commission contracts to | ||
administer claims under the medical assistance program, or a | ||
managed care organization with which the commission contracts to | ||
provide services to recipients under the medical assistance | ||
program, that makes an improper payment on a claim that is subject | ||
to Section 32.0631, to have a right of subrogation against another | ||
entity, including a managed care organization, that is or would | ||
have been responsible for payment of the claim had the claim been | ||
properly filed with that entity; and | ||
(2) identify improvements that should be made to | ||
eligibility determination processes and other administrative | ||
procedures in order to reduce the incidence of retroactive | ||
disenrollment from the medical assistance program that can result | ||
in improper payments. | ||
(b) If, as a result of each study conducted under this | ||
section, the commission determines that implementation of the | ||
studied process or improvements, as applicable, would be feasible | ||
and cost-effective to implement, the commission shall, | ||
notwithstanding any other law, implement the process or | ||
improvements. If the commission implements the process or | ||
improvements, the commission shall modify contracts with an entity | ||
with which the commission contracts to administer claims and | ||
managed care organizations to the extent possible and as necessary | ||
for that implementation. | ||
(c) Not later than December 1, 2016, the commission shall | ||
submit a report to each standing committee of the senate and house | ||
of representatives having primary jurisdiction over the medical | ||
assistance program detailing the results of each study conducted | ||
under this section and, if the commission implemented the | ||
applicable process or improvements in accordance with Subsection | ||
(b), an analysis of the effectiveness of the implementation in | ||
reducing overpayments. This subsection expires September 1, 2017. | ||
SECTION 2. Section 32.0631, Human Resources Code, as added | ||
by this Act, applies only to improper payments for claims made under | ||
the medical assistance program under Chapter 32, Human Resources | ||
Code, that are made on or after the effective date of this Act. A | ||
claim made before the effective date of this Act is governed by the | ||
law as it existed immediately before the effective date of this Act, | ||
and that law is continued in effect for that purpose. | ||
SECTION 3. 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 4. This Act takes effect immediately if it receives | ||
a vote of two-thirds of all the members elected to each house, as | ||
provided by Section 39, Article III, Texas Constitution. If this | ||
Act does not receive the vote necessary for immediate effect, this | ||
Act takes effect September 1, 2015. |