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Amend CSHB 2292 as follows:
(1) On page 11, strike lines 4-6 and substitute the
following:
(2) the office of inspector general to conduct audits
and perform fraud and abuse investigation and enforcement functions
as provided by Subchapter C and other law;
(2) On page 48, line 21, strike "and".
(3) On page 48, line 23, immediately following the
semicolon, insert "and".
(4) On page 48, between lines 23 and 24, insert the
following:
(D) the Texas Department of Human Services office
of inspector general;
(5) On page 50, between lines 19 and 20, insert the
following:
(f) All powers, duties, functions, programs, and activities
relating to audits, including internal audits, transferred to the
Health and Human Services Commission under Subsection (a)(1) of
this section, and all powers, duties, functions, programs, and
activities relating to the Texas Department of Human Services
office of inspector general transferred to the Health and Human
Services Commission under Subsection (a)(2)(D) of this section,
shall be assumed by the commission's office of inspector general.
Notwithstanding any other provision of law, a reference in law to
the Texas Department of Human Services office of inspector general
means the commission's office of inspector general.
(6) Add the following appropriately numbered sections to
Article 2 of the bill:
SECTION ____. The heading to Subchapter C, Chapter 531,
Government Code, is amended to read as follows:
SUBCHAPTER C. MEDICAID AND OTHER HEALTH AND HUMAN SERVICES
[WELFARE] FRAUD, ABUSE, OR OVERCHARGES
SECTION ____. 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) "Hold on payment" means the temporary denial of
reimbursement under the Medicaid program for items or services
furnished by a specified provider.
(3) "Practitioner" means a physician or other
individual licensed under state law to practice the individual's
profession.
(4) "Program exclusion" means the suspension of a
provider from being authorized under the Medicaid program to
request reimbursement for items or services furnished by that
specific provider.
(5) "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.
(7) Strike SECTION 2.15 of the bill (page 74, line 13,
through page 75, line 15) and substitute the following
appropriately numbered section:
SECTION ____. (a) Section 531.102, Government Code, is
amended to read as follows:
Sec. 531.102. [INVESTIGATIONS AND ENFORCEMENT] OFFICE OF
INSPECTOR GENERAL. (a) The commission, through the commission's
office of inspector general [investigations and enforcement], is
responsible for the investigation of fraud and abuse in the
provision of health and human services and the enforcement of state
law relating to the provision of those services. The commission may
obtain any information or technology necessary to enable the office
to meet its responsibilities under this subchapter or other law.
(a-1) The governor shall appoint an inspector general to
serve as director of the office. The inspector general serves a
one-year term that expires on February 1.
(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.
(c) The commission shall train office staff to enable the
staff to pursue priority Medicaid and other health and human
services [welfare] fraud and abuse cases as necessary.
(d) The commission may require employees of health and human
services agencies to provide assistance to the office [commission]
in connection with the office's [commission's] duties relating to
the investigation of fraud and abuse in the provision of health and
human services. The office is entitled to access to any information
maintained by a health and human services agency, including
internal records, relevant to the functions of the office.
(e) The commission, in consultation with the inspector
general, by rule shall set specific claims criteria that, when met,
require the office to begin an investigation.
(f)(1) If the commission receives a complaint of Medicaid
fraud or abuse from any source, the office must conduct an integrity
review to determine whether there is sufficient basis to warrant a
full investigation. An integrity review must begin not later than
the 30th day after the date 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 the 90th day
after it began.
(2) If the findings of an integrity review give the
office reason to believe that an incident of fraud or abuse
involving possible criminal conduct has occurred in the Medicaid
program, the office must take the following action, as appropriate,
not later than the 30th day after the completion of the integrity
review:
(A) if a provider 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, 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 office may
conduct a full investigation of the suspected fraud.
(g)(1) In addition to other instances authorized under state
or federal law, the office shall impose without prior notice a hold
on payment of claims for reimbursement submitted by a provider to
compel production of records or when requested by the state's
Medicaid fraud control unit, as applicable. The office 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 office 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 office learns or has reason to
suspect that a provider'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, the criminal referral does not preclude the office
from continuing its investigation of the provider, which
investigation may lead to the imposition of appropriate
administrative or civil sanctions.
(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 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 funds described by Subdivision (4) and
the prevention and detection of fraud and abuse in administration
of those funds.
(i) Notwithstanding any other provision of law, a reference
in law or rule to the commission's office of investigations and
enforcement means the office of inspector general established under
this section.
(b) As soon as possible after the effective date of this
section, the governor shall appoint a person to serve as inspector
general in accordance with Section 531.102, Government Code, as
amended by this section. The initial term of the person appointed
in accordance with this subsection expires February 1, 2005.
(8) Strike page 75, line 18, through page 76, line 10, and
substitute the following:
Sec. 531.1021. SUBPOENAS. (a) The office of inspector
general may request that the commissioner or the commissioner's
designee approve the issuance by the office of a subpoena in
connection with an investigation conducted by the office. If the
request is approved, the office may issue a subpoena to compel the
attendance of a relevant witness or the production, for inspection
or copying, of relevant evidence that is in this state.
(b) A subpoena may be served personally or by certified
mail.
(c) If a person fails to comply with a subpoena, the office,
acting through the attorney general, may file suit to enforce the
subpoena in a district court in this state.
(d) On finding that good cause exists for issuing the
subpoena, the court shall order the person to comply with the
subpoena. The court may punish a person who fails to obey the court
order.
(e) The office shall pay a reasonable fee for photocopies
subpoenaed under this section in an amount not to exceed the amount
the office may charge for copies of its records.
(f) The reimbursement of the expenses of a witness whose
attendance is compelled under this section is governed by Section
2001.103.
(g) All information and materials subpoenaed or compiled by
the office in connection with an investigation are confidential and
not subject to disclosure under Chapter 552, and not subject to
disclosure, discovery, subpoena, or other means of legal compulsion
for their release to anyone other than the office or its employees
or agents involved in the investigation conducted by the office,
except that this information may be disclosed to the office of the
attorney general and law enforcement agencies.
(9) Strike SECTION 2.17 of the bill (page 76, line 11,
through page 79, line 27) and substitute the following
appropriately numbered section:
SECTION ____. (a) Section 531.103, Government Code, is
amended to read as follows:
Sec. 531.103. INTERAGENCY COORDINATION. (a) The
commission, acting through the commission's office of inspector
general, and the office of the attorney general shall enter into a
memorandum of understanding to develop and implement joint written
procedures for processing cases of suspected fraud, waste, or
abuse, as those terms are defined by state or federal law, or other
violations of state or federal law under the state Medicaid program
or other program administered by the commission or a health and
human services agency, including the financial assistance program
under Chapter 31, Human Resources Code, a nutritional assistance
program under Chapter 33, Human Resources Code, and the child
health plan program. The memorandum of understanding shall
require:
(1) the office of inspector general [commission] and
the office of the attorney general to set priorities and guidelines
for referring cases to appropriate state agencies for
investigation, prosecution, or other disposition to enhance
deterrence of fraud, waste, [or] abuse, or other violations of
state or federal law, including a violation of Chapter 102,
Occupations Code, in the programs [program] and maximize the
imposition of penalties, the recovery of money, and the successful
prosecution of cases;
(1-a) the office of inspector general to refer each
case of suspected provider fraud, waste, or abuse to the office of
the attorney general not later than the 10th business day after the
date the office of inspector general determines that the existence
of fraud, waste, or abuse is reasonably indicated;
(1-b) the office of the attorney general to take
appropriate action in response to each case referred to the
attorney general, which action may include direct initiation of
prosecution or civil litigation or referral to an appropriate
United States attorney, a district attorney, a county attorney, or
a collections agency for initiation of prosecution, civil
litigation, or other appropriate action;
(2) the office of inspector general [commission] to
keep detailed records for cases processed by that office [the
commission] or the office of the attorney general, including
information on the total number of cases processed and, for each
case:
(A) the agency and division to which the case is
referred for investigation;
(B) the date on which the case is referred; and
(C) the nature of the suspected fraud, waste, or
abuse;
(3) the office of inspector general [commission] to
notify each appropriate division of the office of the attorney
general of each case referred by the office of inspector general
[commission];
(4) the office of the attorney general to ensure that
information relating to each case investigated by that office is
available to each division of the office with responsibility for
investigating suspected fraud, waste, or abuse;
(5) the office of the attorney general to notify the
office of inspector general [commission] of each case the attorney
general declines to prosecute or prosecutes unsuccessfully;
(6) representatives of the office of inspector general
[commission] and of the office of the attorney general to meet not
less than quarterly to share case information and determine the
appropriate agency and division to investigate each case; and
(7) the office of inspector general [commission] and
the office of the attorney general to submit information requested
by the comptroller about each resolved case for the comptroller's
use in improving fraud detection.
(b) An exchange of information under this section between
the office of the attorney general and the commission, the office of
inspector general, or a health and human services agency does not
affect whether the information is subject to disclosure under
Chapter 552.
(c) The commission and the office of the attorney general
shall jointly prepare and submit a semiannual report to the
governor, lieutenant governor, [and] speaker of the house of
representatives, and comptroller concerning the activities of
those agencies in detecting and preventing fraud, waste, and abuse
under the state Medicaid program or other program administered by
the commission or a health and human services agency. The report
may be consolidated with any other report relating to the same
subject matter the commission or office of the attorney general is
required to submit under other law.
(d) The commission and the office of the attorney general
may not assess or collect investigation and attorney's fees on
behalf of any state agency unless the office of the attorney general
or other state agency collects a penalty, restitution, or other
reimbursement payment to the state.
(e) In addition to the provisions required by Subsection
(a), the memorandum of understanding required by this section must
also ensure that no barriers to direct fraud referrals to the office
of the attorney general's Medicaid fraud control unit or
unreasonable impediments to communication between Medicaid agency
employees and the Medicaid fraud control unit are imposed, and must
include procedures to facilitate the referral of cases directly to
the office of the attorney general. [The commission shall refer a
case of suspected fraud, waste, or abuse under the state Medicaid
program to the appropriate district attorney, county attorney, city
attorney, or private collection agency if the attorney general
fails to act within 30 days of referral of the case to the office of
the attorney general. A failure by the attorney general to act
within 30 days constitutes approval by the attorney general under
Section 2107.003.]
(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 in
accordance with procedures adopted under this section and 20
percent of the amount of the penalty, restitution, or other
reimbursement payment collected.
(b) Not later than December 1, 2003, the office of the
attorney general and the Health and Human Services Commission shall
amend the memorandum of understanding required by Section 531.103,
Government Code, as necessary to comply with that section, as
amended by this section.
(10) Add the following appropriately numbered section to
Article 2 of the bill:
SECTION ____. Section 531.104(b), Government Code, is
amended to read as follows:
(b) The memorandum of understanding must specify the type,
scope, and format of the investigative support provided to the
attorney general under this section [provide that the commission is
not required to provide investigative support in more than 100 open
investigations in a fiscal year].
(11) Add the following appropriately numbered section to
Article 2 of the bill:
SECTION ____. Subchapter C, Chapter 531, Government Code, is
amended by adding Section 531.116 to read as follows:
Sec. 531.116. COMPLIANCE WITH LAW PROHIBITING
SOLICITATION. A provider who furnishes services under the Medicaid
program or child health plan program is subject to Chapter 102,
Occupations Code, and the provider's compliance with that chapter
is a condition of the provider's eligibility to participate as a
provider under those programs.
(12) On page 83, line 8, strike "investigations and
enforcement" and substitute "inspector general".
(13) On page 83, line 15, strike "investigations and
enforcement" and substitute "inspector general".
(14) On page 84, line 10, strike "investigations and
enforcement" and substitute "inspector general".
(15) On page 84, lines 18 and 19, strike "investigations and
enforcement" and substitute "inspector general".
(16) On page 136, line 8, strike "an irregularity" and
substitute "a pattern of suspected fraud or abuse involving
criminal conduct".
(17) Add the following appropriately numbered sections to
Article 2 of the bill:
SECTION ____. Section 31.03, Penal Code, is amended by
adding Subsection (j) to read as follows:
(j) With the consent of the appropriate local county or
district attorney, the attorney general has concurrent
jurisdiction with that consenting local prosecutor to prosecute an
offense under this section that involves the state Medicaid
program.
SECTION ____. Section 32.45, Penal Code, is amended by
adding Subsection (d) to read as follows:
(d) With the consent of the appropriate local county or
district attorney, the attorney general has concurrent
jurisdiction with that consenting local prosecutor to prosecute an
offense under this section that involves the state Medicaid
program.
SECTION ____. Section 32.46, Penal Code, is amended by
adding Subsection (e) to read as follows:
(e) With the consent of the appropriate local county or
district attorney, the attorney general has concurrent
jurisdiction with that consenting local prosecutor to prosecute an
offense under this section that involves the state Medicaid
program.
SECTION ____. Section 37.10, Penal Code, is amended by
adding Subsection (i) to read as follows:
(i) With the consent of the appropriate local county or
district attorney, the attorney general has concurrent
jurisdiction with that consenting local prosecutor to prosecute an
offense under this section that involves the state Medicaid
program.
(18) Renumber existing sections of the bill appropriately.