Bill Text: TX HB648 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to the duties of the Health and Human Services Commission's office of inspector general.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2021-03-01 - Referred to Human Services [HB648 Detail]
Download: Texas-2021-HB648-Introduced.html
87R593 JG-F | ||
By: Raymond | H.B. No. 648 |
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relating to the duties of the Health and Human Services | ||
Commission's office of inspector general. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 531.102, Government Code, is amended by | ||
amending Subsections (b), (f), (f-1), (h), (n), (p), and (r) and | ||
adding Subsection (z) to read as follows: | ||
(b) The [ |
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general[ |
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standards for the office that emphasize: | ||
(1) coordinating investigative efforts to | ||
aggressively recover money; | ||
(2) allocating resources to cases that have the | ||
strongest supportive evidence [ |
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(3) maximizing opportunities for referral of cases to | ||
the office of the attorney general in accordance with Section | ||
531.103. | ||
(f)(1) If the commission receives a complaint or allegation | ||
of Medicaid fraud or abuse from any source, the office must conduct | ||
a preliminary investigation as provided by Section 531.118(c) to | ||
determine whether there is a sufficient basis to warrant a full | ||
investigation. A preliminary investigation must begin not later | ||
than the 30th day, and be completed not later than the 45th day, | ||
after the date the commission receives a complaint or allegation or | ||
has reason to believe that fraud or abuse has occurred. | ||
(2) If the findings of a preliminary investigation | ||
give the office reason to believe that an incident of fraud or abuse | ||
involving possible criminal conduct has occurred in Medicaid, the | ||
office must take the following action, as appropriate, not later | ||
than the 30th day after the completion of the preliminary | ||
investigation: | ||
(A) if a provider or Medicaid managed care | ||
organization is suspected of fraud or abuse involving criminal | ||
conduct, the office must refer the case to the state's Medicaid | ||
fraud control unit, provided that the criminal referral does not | ||
preclude the office from continuing its investigation of the | ||
provider or Medicaid managed care organization, which | ||
investigation may lead to the imposition of appropriate | ||
administrative or civil sanctions; or | ||
(B) if there is reason to believe that a | ||
recipient has defrauded Medicaid, the office may conduct a full | ||
investigation of the suspected fraud[ |
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(f-1) The office shall complete a full investigation of a | ||
complaint or allegation of Medicaid fraud or abuse against a | ||
provider or Medicaid managed care organization not later than the | ||
180th day after the date the full investigation begins unless the | ||
office determines that more time is needed to complete the | ||
investigation. Except as otherwise provided by this subsection, | ||
if the office determines that more time is needed to complete the | ||
investigation, the office shall provide notice to the provider or | ||
Medicaid managed care organization that [ |
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investigation stating that the length of the investigation will | ||
exceed 180 days and specifying the reasons why the office was unable | ||
to complete the investigation within the 180-day period. The | ||
office is not required to provide notice to the provider or Medicaid | ||
managed care organization under this subsection if the office | ||
determines that providing notice would jeopardize the | ||
investigation. | ||
(h) In addition to performing functions and duties | ||
otherwise provided by law, the office may: | ||
(1) assess administrative penalties otherwise | ||
authorized by law on behalf of the commission or a health and human | ||
services agency; | ||
(2) request that the attorney general obtain an | ||
injunction to prevent a person from disposing of an asset | ||
identified by the office as potentially subject to recovery by the | ||
office due to the person's fraud or abuse; | ||
(3) provide for coordination between the office and | ||
special investigative units formed by managed care organizations | ||
under Section 531.113 or entities with which managed care | ||
organizations contract under that section; | ||
(4) audit the use and effectiveness of state or | ||
federal funds, including contract and grant funds, administered by | ||
a person, [ |
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the funds from a health and human services agency; | ||
(5) conduct investigations relating to the funds | ||
described by Subdivision (4); and | ||
(6) recommend policies promoting economical and | ||
efficient administration of the funds described by Subdivision (4) | ||
and the prevention and detection of fraud and abuse in | ||
administration of those funds. | ||
(n) To the extent permitted under federal law, the executive | ||
commissioner, on behalf of the office, shall adopt rules | ||
establishing the criteria for initiating a full-scale fraud or | ||
abuse investigation, conducting the investigation, collecting | ||
evidence, accepting and approving a provider's request to post a | ||
surety bond to secure potential recoupments in lieu of a payment | ||
hold or other asset or payment guarantee, and establishing minimum | ||
training requirements for Medicaid [ |
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investigators. | ||
(p) The executive commissioner, in consultation with the | ||
office, shall adopt rules establishing criteria: | ||
(1) for opening a case; | ||
(2) for prioritizing cases for the efficient | ||
management of the office's workload, including rules that direct | ||
the office to prioritize: | ||
(A) provider and managed care organization cases | ||
according to the highest [ |
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state [ |
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(B) recipient cases according to the highest | ||
potential for recovery and federal timeliness requirements; and | ||
(C) internal affairs investigations according to | ||
the seriousness of the threat to recipient safety and the risk to | ||
program integrity in terms of the amount or scope of fraud, waste, | ||
and abuse posed by the allegation that is the subject of the | ||
investigation; and | ||
(3) to guide field investigators in closing a case | ||
that is not worth pursuing through a full investigation. | ||
(r) The office shall review the office's investigative | ||
process, including the office's use of sampling and extrapolation | ||
to audit provider and managed care organization records. The | ||
review shall be performed by staff who are not directly involved in | ||
investigations conducted by the office. | ||
(z) Based on the results of an audit, inspection, or | ||
investigation of a managed care organization conducted by the | ||
office under this section, the office may recommend to the | ||
commission that enforcement actions, including the payment of | ||
liquidated damages, be taken against the managed care organization | ||
and suggest the amount of a penalty to be assessed. | ||
SECTION 2. Sections 531.102(g)(1) and (7), Government Code, | ||
are amended to read as follows: | ||
(1) Whenever the office learns or has reason to | ||
suspect that a provider's or Medicaid managed care organization's | ||
records are being withheld, concealed, destroyed, fabricated, or in | ||
any way falsified, the office shall immediately refer the case to | ||
the state's Medicaid fraud control unit. However, such criminal | ||
referral does not preclude the office from continuing its | ||
investigation of the provider or Medicaid managed care | ||
organization, which investigation may lead to the imposition of | ||
appropriate administrative or civil sanctions. | ||
(7) The office shall, in consultation with the state's | ||
Medicaid fraud control unit, establish guidelines under which | ||
program exclusions: | ||
(A) may permissively be imposed on a provider or | ||
Medicaid managed care organization; or | ||
(B) shall automatically be imposed on a provider | ||
or Medicaid managed care organization. | ||
SECTION 3. Sections 531.118(a) and (b), Government Code, | ||
are amended to read as follows: | ||
(a) The commission shall maintain a record of all | ||
allegations of fraud or abuse against a provider or managed care | ||
organization containing the date each allegation was received or | ||
identified and the source of the allegation, if available. The | ||
record is confidential under Section 531.1021(g) and is subject to | ||
Section 531.1021(h). | ||
(b) If the commission receives an allegation of fraud or | ||
abuse against a provider or managed care organization from any | ||
source, the commission's office of inspector general shall conduct | ||
a preliminary investigation of the allegation to determine whether | ||
there is a sufficient basis to warrant a full investigation. A | ||
preliminary investigation must begin not later than the 30th day, | ||
and be completed not later than the 45th day, after the date the | ||
commission receives or identifies an allegation of fraud or abuse. | ||
SECTION 4. Subchapter C, Chapter 531, Government Code, is | ||
amended by adding Section 531.1185 to read as follows: | ||
Sec. 531.1185. REVIEW, RENEGOTIATION, AND REVISION OF | ||
CERTAIN FINAL ORDERS AND SETTLEMENT AGREEMENTS. The office of | ||
inspector general may, on request by a provider, review, | ||
renegotiate, and revise a final order or settlement agreement | ||
currently under repayment entered into by the provider and the | ||
office between January 1, 2011, and December 31, 2014. In | ||
reviewing, renegotiating, and revising a final order or settlement | ||
agreement under this section, the office shall consider: | ||
(1) amounts being paid by the provider under the order | ||
or agreement; | ||
(2) amounts paid or lost by the provider as a result of | ||
any investigation, audit, or inspection that was the basis of the | ||
order or agreement; and | ||
(3) amounts of the federal share paid or being paid. | ||
SECTION 5. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.0122 to read as follows: | ||
Sec. 533.0122. UTILIZATION REVIEW AUDITS CONDUCTED BY | ||
OFFICE OF INSPECTOR GENERAL. (a) If the commission's office of | ||
inspector general intends to conduct a utilization review audit of | ||
a provider of services under a Medicaid managed care delivery | ||
model, the office shall inform both the provider and the Medicaid | ||
managed care organization with which the provider contracts of any | ||
applicable criteria and guidelines the office will use in the | ||
course of the audit. | ||
(b) The commission's office of inspector general shall | ||
ensure that each person conducting a utilization review audit under | ||
this section has experience and training regarding the operations | ||
of Medicaid managed care organizations. | ||
(c) The commission's office of inspector general may not, as | ||
the result of a utilization review audit, recoup an overpayment or | ||
debt from a provider that contracts with a Medicaid managed care | ||
organization based on a determination that a provided service was | ||
not medically necessary unless the office: | ||
(1) uses the same criteria and guidelines that were | ||
used by the managed care organization in its determination of | ||
medical necessity for the service; and | ||
(2) verifies with the managed care organization and | ||
the provider that the provider: | ||
(A) at the time the service was delivered, had | ||
reasonable notice of the criteria and guidelines used by the | ||
managed care organization to determine medical necessity; and | ||
(B) did not follow the criteria and guidelines | ||
used by the managed care organization to determine medical | ||
necessity that were in effect at the time the service was delivered. | ||
SECTION 6. Not later than December 31, 2021, the executive | ||
commissioner of the Health and Human Services Commission shall | ||
adopt rules necessary to implement the changes in law made by this | ||
Act. | ||
SECTION 7. 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 8. This Act takes effect September 1, 2021. |