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: Bipartisan Bill
Status: (Passed) 2017-06-15 - Effective on 9/1/17 [SB894 Detail]
Download: Texas-2017-SB894-Enrolled.html
S.B. No. 894 |
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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), [ |
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shall, in accordance with federal law, implement an electronic | ||
visit verification system to electronically verify [ |
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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[ |
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(1) the type of service provided [ |
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(2) the name of the recipient to whom the service is | ||
provided [ |
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(3) the date and times [ |
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(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 |