Bill Text: TX SB894 | 2017-2018 | 85th Legislature | Enrolled


Bill Title: Relating to auditing and verification of information under certain health and human services programs, including the collection of certain payments following an investigation.

Spectrum: Moderate Partisan Bill (Democrat 4-1)

Status: (Passed) 2017-06-15 - Effective on 9/1/17 [SB894 Detail]

Download: Texas-2017-SB894-Enrolled.html
 
 
  S.B. No. 894
 
 
 
 
AN ACT
  relating to auditing and verification of information under certain
  health and human services programs, including the collection of
  certain payments following an investigation.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 321.013, Government Code, is amended by
  adding Subsection (m) to read as follows:
         (m)  In devising the audit plan under Subsection (c), the
  State Auditor shall consider the performance of audits of programs
  operated by health and human services agencies that:
               (1)  have not recently received audit coverage; and
               (2)  have expenditures of less than $100 million per
  year.
         SECTION 2.  Section 531.024172, Government Code, is amended
  to read as follows:
         Sec. 531.024172.  ELECTRONIC VISIT VERIFICATION SYSTEM.
  (a)  Not later than March 31, 2018, the commission shall conduct a
  review of the electronic visit verification system in use under
  this section on August 31, 2017. Notwithstanding any other
  provision of this section, the commission is required to implement
  a change in law made to this section by S.B. 894, Acts of the 85th
  Legislature, Regular Session, 2017, only if the commission
  determines the implementation is appropriate based on the findings
  of the review. The commission may combine the review required by
  this subsection with any similar review required to be conducted by
  the commission.
         (b)  Subject to Subsection (g), [In this section, "acute
  nursing services" has the meaning assigned by Section 531.02417.
         [(b)  If it is cost-effective and feasible,] the commission
  shall, in accordance with federal law, implement an electronic
  visit verification system to electronically verify [and document,]
  through a telephone, global positioning, or computer-based system
  that personal care services, attendant care services, or other
  services identified by the commission that are provided to
  recipients under Medicaid, including personal care services or
  attendant care services provided under the Texas Health Care
  Transformation and Quality Improvement Program waiver issued under
  Section 1115 of the federal Social Security Act (42 U.S.C. Section
  1315) or any other Medicaid waiver program, are provided to
  recipients in accordance with a prior authorization or plan of
  care. The electronic visit verification system implemented under
  this subsection must allow for verification of only the following[,
  basic] information relating to the delivery of Medicaid [acute
  nursing] services[, including]:
               (1)  the type of service provided [the provider's
  name];
               (2)  the name of the recipient to whom the service is
  provided [the recipient's name]; [and]
               (3)  the date and times [time] the provider began
  [begins] and ended the [ends each] service delivery visit;
               (4)  the location, including the address, at which the
  service was provided;
               (5)  the name of the individual who provided the
  service; and
               (6)  other information the commission determines is
  necessary to ensure the accurate adjudication of Medicaid claims.
         (c)  The commission shall inform each Medicaid recipient who
  receives personal care services, attendant care services, or other
  services identified by the commission that the health care provider
  providing the services and the recipient are each required to
  comply with the electronic visit verification system.  A managed
  care organization that contracts with the commission to provide
  health care services to Medicaid recipients described by this
  subsection shall also inform recipients enrolled in a managed care
  plan offered by the organization of those requirements.
         (d)  In implementing the electronic visit verification
  system:
               (1)  subject to Subsection (e), the executive
  commissioner shall adopt compliance standards for health care
  providers; and
               (2)  the commission shall ensure that:
                     (A)  the information required to be reported by
  health care providers is standardized across managed care
  organizations that contract with the commission to provide health
  care services to Medicaid recipients and across commission
  programs;
                     (B)  processes required by managed care
  organizations to retrospectively correct data are standardized and
  publicly accessible to health care providers; and
                     (C)  standardized processes are established for
  addressing the failure of a managed care organization to provide a
  timely authorization for delivering services necessary to ensure
  continuity of care.
         (e)  In establishing compliance standards for health care
  providers under Subsection (d), the executive commissioner shall
  consider:
               (1)  the administrative burdens placed on health care
  providers required to comply with the standards; and
               (2)  the benefits of using emerging technologies for
  ensuring compliance, including Internet-based, mobile
  telephone-based, and global positioning-based technologies.
         (f)  A health care provider that provides personal care
  services, attendant care services, or other services identified by
  the commission to Medicaid recipients shall:
               (1)  use an electronic visit verification system to
  document the provision of those services;
               (2)  comply with all documentation requirements
  established by the commission;
               (3)  comply with applicable federal and state laws
  regarding confidentiality of recipients' information;
               (4)  ensure that the commission or the managed care
  organization with which a claim for reimbursement for a service is
  filed may review electronic visit verification system
  documentation related to the claim or obtain a copy of that
  documentation at no charge to the commission or the organization;
  and
               (5)  at any time, allow the commission or a managed care
  organization with which a health care provider contracts to provide
  health care services to recipients enrolled in the organization's
  managed care plan to have direct, on-site access to the electronic
  visit verification system in use by the health care provider.
         (g)  The commission may recognize a health care provider's
  proprietary electronic visit verification system as complying with
  this section and allow the health care provider to use that system
  for a period determined by the commission if the commission
  determines that the system:
               (1)  complies with all necessary data submission,
  exchange, and reporting requirements established under this
  section;
               (2)  meets all other standards and requirements
  established under this section; and
               (3)  has been in use by the health care provider since
  at least June 1, 2014.
         (h)  The commission shall create a stakeholder work group
  comprised of representatives of affected health care providers,
  managed care organizations, and Medicaid recipients and
  periodically solicit from that work group input regarding the
  ongoing operation of the electronic visit verification system under
  this section.
         (i)  The executive commissioner may adopt rules necessary to
  implement this section.
         SECTION 3.  Section 531.120, Government Code, is amended by
  adding Subsection (c) to read as follows:
         (c)  The commission shall provide the notice required by
  Subsection (a) to a provider that is a hospital not later than the
  90th day before the date the overpayment or debt that is the subject
  of the notice must be paid.
         SECTION 4.  Chapter 533, Government Code, is amended by
  adding Subchapter B to read as follows:
  SUBCHAPTER B. STRATEGY FOR MANAGING AUDIT RESOURCES
         Sec. 533.051.  DEFINITIONS. In this subchapter:
               (1)  "Accounts receivable tracking system" means the
  system the commission uses to track experience rebates and other
  payments collected from managed care organizations.
               (2)  "Agreed-upon procedures engagement" means an
  evaluation of a managed care organization's financial statistical
  reports or other data conducted by an independent auditing firm
  engaged by the commission as agreed in the managed care
  organization's contract with the commission.
               (3)  "Experience rebate" means the amount a managed
  care organization is required to pay the state according to the
  graduated rebate method described in the managed care
  organization's contract with the commission.
               (4)  "External quality review organization" means an
  organization that performs an external quality review of a managed
  care organization in accordance with 42 C.F.R. Section 438.350.
         Sec. 533.052.  APPLICABILITY AND CONSTRUCTION OF
  SUBCHAPTER. This subchapter does not apply to and may not be
  construed as affecting the conduct of audits by the commission's
  office of inspector general under the authority provided by
  Subchapter C, Chapter 531, including an audit of a managed care
  organization conducted by the office after coordinating the
  office's audit and oversight activities with the commission as
  required by Section 531.102(q), as added by Chapter 837 (S.B. 200),
  Acts of the 84th Legislature, Regular Session, 2015.
         Sec. 533.053.  OVERALL STRATEGY FOR MANAGING AUDIT
  RESOURCES. The commission shall develop and implement an overall
  strategy for planning, managing, and coordinating audit resources
  that the commission uses to verify the accuracy and reliability of
  program and financial information reported by managed care
  organizations.
         Sec. 533.054.  PERFORMANCE AUDIT SELECTION PROCESS AND
  FOLLOW-UP.  (a)  To improve the commission's processes for
  performance audits of managed care organizations, the commission
  shall:
               (1)  document the process by which the commission
  selects managed care organizations to audit;
               (2)  include previous audit coverage as a risk factor
  in selecting managed care organizations to audit; and
               (3)  prioritize the highest risk managed care
  organizations to audit.
         (b)  To verify that managed care organizations correct
  negative performance audit findings, the commission shall:
               (1)  establish a process to:
                     (A)  document how the commission follows up on
  negative performance audit findings; and
                     (B)  verify that managed care organizations
  implement performance audit recommendations; and
               (2)  establish and implement policies and procedures
  to:
                     (A)  determine under what circumstances the
  commission must issue a corrective action plan to a managed care
  organization based on a performance audit; and
                     (B)  follow up on the managed care organization's
  implementation of the corrective action plan.
         Sec. 533.055.  AGREED-UPON PROCEDURES ENGAGEMENTS AND
  CORRECTIVE ACTION PLANS.  To enhance the commission's use of
  agreed-upon procedures engagements to identify managed care
  organizations' performance and compliance issues, the commission
  shall:
               (1)  ensure that financial risks identified in
  agreed-upon procedures engagements are adequately and consistently
  addressed; and
               (2)  establish policies and procedures to determine
  under what circumstances the commission must issue a corrective
  action plan based on an agreed-upon procedures engagement.
         Sec. 533.056.  AUDITS OF PHARMACY BENEFIT MANAGERS. To
  obtain greater assurance about the effectiveness of pharmacy
  benefit managers' internal controls and compliance with state
  requirements, the commission shall:
               (1)  periodically audit each pharmacy benefit manager
  that contracts with a managed care organization; and
               (2)  develop, document, and implement a monitoring
  process to ensure that managed care organizations correct and
  resolve negative findings reported in performance audits or
  agreed-upon procedures engagements of pharmacy benefit managers.
         Sec. 533.057.  COLLECTION OF COSTS FOR AUDIT-RELATED
  SERVICES. The commission shall develop, document, and implement
  billing processes in the Medicaid and CHIP services department of
  the commission to ensure that managed care organizations reimburse
  the commission for audit-related services as required by contract.
         Sec. 533.058.  COLLECTION ACTIVITIES RELATED TO PROFIT
  SHARING. To strengthen the commission's process for collecting
  shared profits from managed care organizations, the commission
  shall develop, document, and implement monitoring processes in the
  Medicaid and CHIP services department of the commission to ensure
  that the commission:
               (1)  identifies experience rebates deposited in the
  commission's suspense account and timely transfers those rebates to
  the appropriate accounts; and
               (2)  timely follows up on and resolves disputes over
  experience rebates claimed by managed care organizations.
         Sec. 533.059.  USE OF INFORMATION FROM EXTERNAL QUALITY
  REVIEWS. (a)  To enhance the commission's monitoring of managed
  care organizations, the commission shall use the information
  provided by the external quality review organization, including:
               (1)  detailed data from results of surveys of Medicaid
  recipients and, if applicable, child health plan program enrollees,
  caregivers of those recipients and enrollees, and Medicaid and, as
  applicable, child health plan program providers; and
               (2)  the validation results of matching paid claims
  data with medical records.
         (b)  The commission shall document how the commission uses
  the information described by Subsection (a) to monitor managed care
  organizations.
         Sec. 533.060.  SECURITY AND PROCESSING CONTROLS OVER
  INFORMATION TECHNOLOGY SYSTEMS. The commission shall:
               (1)  strengthen user access controls for the
  commission's accounts receivable tracking system and network
  folders that the commission uses to manage the collection of
  experience rebates;
               (2)  document daily reconciliations of deposits
  recorded in the accounts receivable tracking system to the
  transactions processed in:
                     (A)  the commission's cost accounting system for
  all health and human services agencies; and
                     (B)  the uniform statewide accounting system; and
               (3)  develop, document, and implement a process to
  ensure that the commission formally documents:
                     (A)  all programming changes made to the accounts
  receivable tracking system; and
                     (B)  the authorization and testing of the changes
  described by Paragraph (A).
         SECTION 5.  (a)  As soon as practicable after March 31,
  2018, and to the extent appropriate based on the review conducted by
  the Health and Human Services Commission under Section
  531.024172(a), Government Code, as amended by this Act, the
  commission shall implement an electronic visit verification system
  that complies with Section 531.024172, Government Code, as amended
  by this Act.
         (b)  As soon as practicable after the effective date of this
  Act, the executive commissioner of the Health and Human Services
  Commission shall adopt the rules necessary to implement Subchapter
  B, Chapter 533, Government Code, as added by this Act.
         SECTION 6.  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 7.  This Act takes effect September 1, 2017.
 
 
 
 
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
         I hereby certify that S.B. No. 894 passed the Senate on
  April 18, 2017, by the following vote:  Yeas 31, Nays 0;
  May 25, 2017, Senate refused to concur in House amendments and
  requested appointment of Conference Committee; May 26, 2017, House
  granted request of the Senate; May 28, 2017, Senate adopted
  Conference Committee Report by the following vote:  Yeas 29,
  Nays 1.
 
 
  ______________________________
  Secretary of the Senate    
 
         I hereby certify that S.B. No. 894 passed the House, with
  amendments, on May 21, 2017, by the following vote:  Yeas 142,
  Nays 0, one present not voting; May 26, 2017, House granted request
  of the Senate for appointment of Conference Committee;
  May 28, 2017, House adopted Conference Committee Report by the
  following vote:  Yeas 141, Nays 0, one present not voting.
 
 
  ______________________________
  Chief Clerk of the House   
 
 
 
  Approved:
 
  ______________________________ 
             Date
 
 
  ______________________________ 
            Governor
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