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) 2021-03-01 - Referred to Human Services [HB648 Detail]

Download: Texas-2021-HB648-Introduced.html
  87R593 JG-F
 
  By: Raymond H.B. No. 648
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  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 [commission, in consultation with the] inspector
  general[,] shall set clear objectives, priorities, and performance
  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 [and the greatest potential for
  recovery of money]; and
               (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[, subject to Section
  531.118(c)].
         (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 [who] is the subject of the
  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, [or] state agency, or managed care organization receiving
  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 [provider] fraud or abuse
  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 [potential for recovery or] risk to the
  state [as indicated through the provider's volume of billings, the
  provider's history of noncompliance with the law, and identified
  fraud trends];
                     (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.
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