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Amend HB 1743 as follows:
(1) On page 2, line 15, strike "an irregularity" and
substitute "a pattern of suspected fraud or abuse involving
criminal conduct".
(2) On page 9, between lines 3 and 4, insert a new SECTION 8
to read as follows and renumber the subsequent sections of the bill
appropriately:
SECTION 8. Subchapter C, Chapter 531, Government Code, is
amended by adding Section 531.1011 to read as follows:
Sec. 531.1011. DEFINITIONS. For purposes of this
subchapter:
(1) "Fraud" means an intentional deception or
misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit to that person
or some other person, including any act that constitutes fraud
under applicable federal or state law.
(2) "Furnished" refers to items or services provided
directly by, or under the direct supervision of, or ordered by, a
practitioner or other individual (either as an employee or in the
individual's own capacity), a provider, or other supplier of
services, excluding services ordered by one party but billed for
and provided by or under the supervision of another.
(3) "Hold on payment" means the temporary denial of
reimbursement under the Medicaid program for items or services
furnished by a specified provider.
(4) "Practitioner" means a physician or other
individual licensed under state law to practice the individual's
profession.
(5) "Program exclusion" means the suspension of a
provider from being authorized under the Medicaid program to
request reimbursement of items or services furnished by that
specific provider.
(6) "Provider" means a person, firm, partnership,
corporation, agency, association, institution, or other entity
that was or is approved by the commission to:
(A) provide medical assistance under contract or
provider agreement with the commission; or
(B) provide third-party billing vendor services
under a contract or provider agreement with the commission.
(3) On page 9, strike lines 17-27, and on page 10, strike
lines 1-4, and substitute the following:
(f) (1) If the commission receives a complaint of Medicaid
fraud or abuse from any source, it must conduct an integrity review
to determine whether there is sufficient basis to warrant a full
investigation. An integrity review must commence not later than 60
days after the commission receives a complaint or has reason to
believe that fraud or abuse has occurred. An integrity review shall
be completed not later than 90 days after it has commenced.
(2) If the findings of an integrity review give the
commission reason to believe that an incident of fraud or abuse
involving possible criminal conduct has occurred in the Medicaid
program, the commission must take the following action, as
appropriate, not later than 30 days after the completion of the
integrity review:
(A) if a provider is suspected of fraud or abuse
involving criminal conduct, the commission must refer the case to
the state's Medicaid fraud control unit, provided that such
criminal referral does not preclude the commission from continuing
its investigation of the provider, 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 the Medicaid program, the commission may
conduct a full investigation of the suspected fraud.
(g) (1) In addition to other instances authorized under
state or federal law, the commission shall impose a hold on payment
of claims for reimbursement submitted by a provider without prior
notice, as applicable, to compel production of records or when
requested by the state's Medicaid fraud control unit. The
commission must notify the provider of the hold on payment not later
than the fifth working day after the date the payment hold is
imposed.
(2) The commission shall, in consultation with the
state's Medicaid fraud control unit, establish guidelines under
which holds on payment or program exclusions:
(A) may permissively be imposed on a provider; or
(B) shall automatically be imposed on a provider.
(3) Whenever the commission learns or has reason to
suspect that a provider's records are being withheld, concealed,
destroyed, fabricated, or in any way falsified, the commission
shall immediately refer the case to the state's Medicaid fraud
control unit. However, such criminal referral does not preclude
the commission from continuing its investigation of the provider,
which investigation may lead to the imposition of appropriate
administrative or civil sanctions.
(4) Strike SECTION 10 of the bill (page 10, line 27, through
page 12, line 12) and substitute the following appropriately
numbered section:
SECTION ___. Section 531.103(f), Government Code, is amended
to read as follows:
(f) A [The] district attorney, county attorney, city
attorney, or private collection agency may collect and retain costs
associated with a [the] case referred to the attorney or agency and
20 percent of the amount of the penalty, restitution, or other
reimbursement payment collected.
(5) On page 12, between lines 12 and 13, insert the
following appropriately numbered section and renumber subsequent
sections of the bill appropriately:
SECTION ___. Section 531.104, Government Code, is amended by
adding Subsection (c) to read as follows:
(c) The memorandum of understanding must ensure that no
barriers to direct fraud referrals to the state's Medicaid fraud
control unit by Medicaid agencies or unreasonable impediments to
communication between Medicaid agency employees and the state's
Medicaid fraud control unit will be imposed.
(6) On page 13, strike lines 25 and 26 and substitute
"531.104, Government Code, as necessary to comply with Section
531.104(c), Government Code, as added by this Act."
(7) On page 14, between lines 15 and 16, insert the
following appropriately numbered section and renumber subsequent
sections of the bill appropriately:
SECTION ___. Section 531.103(e), Government Code, is
repealed.