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A BILL TO BE ENTITLED
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AN ACT
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relating to the office of inspector general. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 531, Government Code, is amended by |
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adding Subchapter M to read as follows: |
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SUBCHAPTER M. INSPECTOR GENERAL |
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Sec. 531.451. DEFINITIONS. In this subchapter: |
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(1) "Fraud" has the meaning assigned by Section |
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531.1011. |
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(2) "Inspector general" means the inspector general |
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appointed under this subchapter. |
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(3) "Office" means the Office of the Inspector |
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General. |
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(4) "Provider" has the meaning assigned by Section |
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531.1011. |
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(5) "Review" includes an inspection, investigation, |
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audit, or similar activity. |
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(6) "State funds" or "state money" includes federal |
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funds or money received and appropriated by the state or for which |
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the state has oversight responsibility. |
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Sec. 531.452. REFERENCE IN OTHER LAW. Notwithstanding any |
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other provision of law, a reference in law or rule to the |
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commission's office of inspector general or the commission's office |
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of investigations and enforcement means the Office of the Inspector |
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General. |
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Sec. 531.453. OFFICE OF INSPECTOR GENERAL; ADMINISTRATIVE |
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ATTACHMENT. (a) The office of inspector general is responsible |
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for: |
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(1) the investigation of fraud, waste, and abuse in |
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the provision or funding of health or human services by this state; |
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(2) the enforcement of state law relating to the |
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provision of those services to protect the public; and |
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(3) the prevention and detection of crime relating to |
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the provision of those services. |
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(b) The office is administratively attached to the |
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commission. The commission shall provide to the office |
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administrative support services from the commission and from the |
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health and human services agency. |
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Sec. 531.454. SERVICE LEVEL AGREEMENT; FUNDS. (a) The |
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commission and the office shall enter into a service level |
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agreement that establishes the performance standards and |
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deliverables with regard to administrative support by the |
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commission. |
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(b) The service level agreement must be reviewed at least |
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annually to ensure that services and deliverables are provided in |
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accordance with the agreement. |
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(c) The commission shall request, apply for, and receive for |
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the office any appropriations or other money from this state or the |
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federal government. |
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(d) The commission shall provide to the office for the state |
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fiscal biennium beginning September 1, 2007, the same level of |
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administrative support the commission provided to the office |
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established under former Section 531.102 for the state fiscal |
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biennium beginning September 1, 2005. This subsection expires |
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January 1, 2010. |
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Sec. 531.455. DUTIES OF COMMISSION. (a) The commission |
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shall: |
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(1) provide administrative assistance to the office; |
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and |
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(2) coordinate administrative responsibilities with |
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the office to avoid unnecessary duplication of duties. |
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(b) The commission may not take an action that affects or |
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relates to the validity, status, or terms of an interagency |
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agreement or a contract to which the office is a party without the |
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office's approval. |
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Sec. 531.456. INDEPENDENCE OF OFFICE. (a) Except as |
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otherwise provided by this chapter, the office and inspector |
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general operate independently of the commission. |
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(b) The inspector general and the office staff are not |
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employees of the commission. |
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Sec. 531.457. INSPECTOR GENERAL: APPOINTMENT AND TERM. (a) |
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The governor shall appoint an inspector general to serve as |
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director of the office. |
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(b) The inspector general serves a two-year term that |
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expires on February 1 of each odd-numbered year. |
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Sec. 531.458. CONFLICT OF INTEREST. (a) The inspector |
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general may not serve as an ex officio member on the governing body |
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of a governmental entity. |
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(b) The inspector general may not have a financial interest |
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in the transactions of the office, a health and human services |
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agency, or a health or human services provider. |
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Sec. 531.459. RULEMAKING BY INSPECTOR GENERAL. (a) |
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Notwithstanding Section 531.0055(e) and any other law, the |
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inspector general shall adopt the rules necessary to administer the |
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functions of the office, including rules to address the imposition |
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of sanctions and penalties for violations and due process |
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requirements for imposing sanctions and penalties. |
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(b) A rule, standard, or form adopted by the executive |
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commissioner, commission, or a health and human services agency |
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that is necessary to accomplish the duties of the office is |
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considered to also be a rule, standard, or form of the office and |
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remains in effect as a rule, standard, or form of the office until |
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changed by the inspector general. |
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(c) The office may submit proposed rules to the commission |
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for publication. The executive commissioner or commission may not |
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amend or modify a rule submitted by the office. |
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(d) The rules must include standards for the office that |
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emphasize: |
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(1) coordinating investigative efforts to |
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aggressively recover money; |
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(2) allocating resources to cases that have the |
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strongest supportive evidence and the greatest potential for |
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recovery of money; and |
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(3) maximizing opportunities for referral of cases to |
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the office of the attorney general. |
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Sec. 531.460. EMPLOYEES; TRAINING. (a) The inspector |
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general may employ personnel as necessary to implement the duties |
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of the office. |
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(b) The inspector general shall train office personnel to |
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pursue priority Medicaid and other health and human services fraud, |
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waste, and abuse cases efficiently and as necessary. |
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(c) The inspector general may contract with certified |
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public accountants, management consultants, or other professional |
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experts necessary to enable the inspector general and office |
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personnel to independently perform the functions of the inspector |
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general's office. |
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(d) The inspector general may require employees of health |
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and human services agencies to provide assistance to the office in |
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connection with the office's duties relating to the investigation |
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of fraud, waste, and abuse in the provision of health and human |
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services. |
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Sec. 531.461. REVIEW AND AUDIT AUTHORITY. (a) The |
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inspector general may evaluate any activity or operation of a |
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health and human services agency, health or human services |
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provider, or person in this state that is related to the |
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investigation, detection, or prevention of fraud or employee |
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misconduct in a state or state-funded health or human services |
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program. A review may include an investigation or other inquiry |
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into a specific act or allegation of, or a specific financial |
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transaction or practice that may involve, impropriety, |
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malfeasance, or nonfeasance in the obligation, spending, receipt, |
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or other use of state money. |
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(b) The executive commissioner, commission, or a health and |
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human services agency of this state may not impair or prohibit the |
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inspector general from initiating or completing a review. |
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(c) The inspector general may audit and review the use and |
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effectiveness of state funds, including contract and grant funds, |
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administered by a person or state agency receiving the funds in |
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connection with a state or state-funded health or human services |
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program. |
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Sec. 531.462. INITIATION OF REVIEW. The inspector general |
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may initiate a review: |
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(1) on the inspector general's own initiative; |
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(2) at the request of the commission or executive |
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commissioner; or |
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(3) based on a complaint from any source concerning a |
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matter described by Section 531.461. |
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Sec. 531.463. INTEGRITY REVIEW. (a) The office shall |
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conduct an integrity review to determine whether there is |
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sufficient basis to warrant a full investigation on receipt of any |
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complaint of fraud, waste, or abuse of funds in the state Medicaid |
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program from any source. |
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(b) An integrity review must begin not later than the 30th |
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day after the date the office receives a complaint or has reason to |
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believe that Medicaid fraud, waste, or abuse has occurred. An |
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integrity review shall be completed not later than the 90th day |
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after the date the review began. |
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(c) If the findings of an integrity review give the office |
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reason to believe that an incident of fraud involving possible |
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criminal conduct has occurred in the state Medicaid program, the |
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office must take the following action, as appropriate, not later |
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than the 30th day after the completion of the integrity review: |
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(1) if a provider is suspected of fraud involving |
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criminal conduct, the office must refer the case to the state's |
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Medicaid fraud control unit, provided that the criminal referral |
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does not preclude the office from continuing its investigation of |
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the provider or preclude the imposition of appropriate |
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administrative or civil sanctions; or |
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(2) if there is reason to believe that a recipient of |
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funds has defrauded the Medicaid program, the office may conduct a |
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full investigation of the suspected fraud. |
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Sec. 531.464. ACCESS TO INFORMATION. (a) To further a |
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review conducted by the office, the inspector general is entitled |
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to access all books, accounts, reports, vouchers, or other |
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information, including confidential information, electronic data, |
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and internal records relevant to the functions of the office, |
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maintained by a person, health and human services agency, or health |
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or human services provider in connection with a state or |
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state-funded health or human services program. |
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(b) The inspector general may not access data or other |
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information the release of which is restricted under federal law |
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unless the appropriate federal agency approves the release to the |
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office or its agent. |
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Sec. 531.465. COOPERATION REQUIRED. To further a review |
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conducted by the inspector general's office, the inspector general |
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may require medical or other professional assistance from the |
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executive commissioner, the commission, a health and human services |
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agency, or an auditor, accountant, or other employee of the |
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commission or agency. |
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Sec. 531.466. REFERRAL TO STATE MEDICAID FRAUD CONTROL |
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UNIT. (a) At the time the office learns or has reason to suspect |
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that a health or human services provider's records related to |
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participation in the state Medicaid program are being withheld, |
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concealed, destroyed, fabricated, or in any way falsified, the |
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office shall immediately refer the case to the state's Medicaid |
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fraud control unit. |
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(b) A criminal referral under Subsection (a) does not |
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preclude the office from continuing its investigation of a health |
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or human services provider or the imposition of appropriate |
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administrative or civil sanctions. |
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Sec. 531.467. HOLD ON CLAIM REIMBURSEMENT PAYMENT; |
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EXCLUSION FROM PROGRAMS. (a) In addition to other instances |
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authorized under state or federal law, the office shall impose |
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without prior notice a hold on payment of claims for reimbursement |
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submitted by a health or human services provider to compel |
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production of records related to participation in the state |
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Medicaid program or on request of the state's Medicaid fraud |
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control unit, as applicable. |
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(b) The office must notify the health or human services |
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provider of the hold on payment not later than the fifth working day |
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after the date the payment hold is imposed. |
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(c) The office shall, in consultation with the state's |
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Medicaid fraud control unit, establish guidelines under which holds |
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on payment or exclusions from a state or state-funded program: |
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(1) may permissively be imposed on a health or human |
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services provider; or |
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(2) shall automatically be imposed on a provider. |
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(d) A health or human services provider subject to a hold on |
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payment or excluded from a program under this section is entitled to |
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a hearing on the hold or exclusion. A hearing under this subsection |
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is a contested case hearing under Chapter 2001. The State Office of |
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Administrative Hearings shall conduct the hearing. After the |
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hearing, the office, subject to judicial review, shall make a final |
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determination. The commission, a health and human services agency, |
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and the office of the attorney general are entitled to intervene as |
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parties in the contested case. |
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Sec. 531.468. REQUEST FOR EXPEDITED HEARING. (a) On timely |
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written request by a health or human services provider subject to a |
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hold on payment under Section 531.467, other than a hold requested |
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by the state's Medicaid fraud control unit, the office shall file a |
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request with the State Office of Administrative Hearings for an |
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expedited administrative hearing regarding the hold. |
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(b) The health or human services provider must request an |
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expedited hearing not later than the 10th day after the date the |
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provider receives notice from the office under Section 531.467(b). |
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Sec. 531.469. INFORMAL RESOLUTION. (a) The inspector |
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general shall adopt rules that allow a health or human services |
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provider subject to a hold on payment under Section 531.467, other |
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than a hold requested by the state's Medicaid fraud control unit, to |
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seek an informal resolution of the issues identified by the office |
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in the notice provided under that section. |
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(b) A health or human services provider must seek an |
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informal resolution not later than the 10th day after the date the |
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provider receives notice from the office under Section 531.467(b). |
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(c) A health or human services provider's decision to seek |
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an informal resolution does not extend the time by which the |
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provider must request an expedited administrative hearing under |
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Section 531.468. |
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(d) A hearing initiated under Section 531.467 shall be |
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stayed at the office's request until the informal resolution |
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process is completed. |
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Sec. 531.470. EMPLOYEE REPORTS. The inspector general may |
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require employees at the commission or a health and human services |
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agency to report to the office information regarding fraud, waste, |
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misuse or abuse of funds or resources, corruption, or illegal acts. |
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Sec. 531.471. SUBPOENAS. (a) The inspector general may |
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issue a subpoena to compel the attendance of a relevant witness or |
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the production, for inspection or copying, of relevant evidence in |
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connection with a review conducted under this subchapter. |
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(b) A subpoena may be served personally or by certified |
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mail. |
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(c) If a person fails to comply with a subpoena, the |
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inspector general, acting through the attorney general, may file |
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suit to enforce the subpoena in a district court in this state. |
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(d) On finding that good cause exists for issuing the |
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subpoena, the court shall order the person to comply with the |
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subpoena. The court may hold in contempt a person who fails to obey |
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the court order. |
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(e) The reimbursement of the expenses of a witness whose |
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attendance is compelled under this section is governed by Section |
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2001.103. |
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Sec. 531.472. INTERNAL AUDITOR. (a) In this section, |
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"internal auditor" means a person appointed under Section 2102.006. |
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(b) The internal auditor for a health and human services |
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agency shall provide the inspector general with a copy of the |
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agency's internal audit plan to: |
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(1) assist in the coordination of efforts between the |
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inspector general and the internal auditor; and |
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(2) limit duplication of effort regarding reviews by |
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the inspector general and internal auditor. |
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(c) The internal auditor shall provide to the inspector |
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general all final audit reports concerning audits of any: |
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(1) part or division of the agency; |
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(2) contract, procurement, or grant; and |
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(3) program conducted by the agency. |
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Sec. 531.473. COOPERATION WITH LAW ENFORCEMENT OFFICIALS |
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AND OTHER ENTITIES. (a) The inspector general may provide |
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information and evidence relating to criminal acts to the state |
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auditor's office and appropriate law enforcement officials. |
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(b) The inspector general may refer matters for further |
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civil, criminal, and administrative action to appropriate |
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administrative and prosecutorial agencies, including the attorney |
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general. |
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(c) The inspector general may enter into a memorandum of |
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understanding with a law enforcement or prosecutorial agency, |
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including the office of the attorney general, to assist in |
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conducting a review under this subchapter. |
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Sec. 531.474. COOPERATION AND COORDINATION WITH STATE |
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AUDITOR. (a) The state auditor may, on request of the inspector |
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general, provide appropriate information or other assistance to the |
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inspector general or office, as determined by the state auditor. |
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(b) The inspector general may meet with the state auditor's |
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office to coordinate a review conducted under this subchapter, |
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share information, or schedule work plans. |
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(c) The state auditor is entitled to access all information |
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maintained by the inspector general, including vouchers, |
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electronic data, internal records, and information obtained under |
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Section 531.464 or subject to Section 531.481. |
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(d) Any information obtained or provided by the state |
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auditor under this section is confidential and not subject to |
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disclosure under Chapter 552. |
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Sec. 531.475. PREVENTION. (a) The inspector general may |
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recommend to the commission and executive commissioner policies on: |
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(1) promoting economical and efficient administration |
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of state funds administered by an individual or entity that |
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received the funds from a health and human services agency; and |
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(2) preventing and detecting fraud, waste, and abuse |
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in the administration of those funds. |
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(b) The inspector general may provide training or other |
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education regarding the prevention of fraud, waste, or abuse to |
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employees of a health and human services agency. The training or |
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education provided must be approved by the presiding officer of the |
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agency. |
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Sec. 531.476. RULEMAKING BY EXECUTIVE COMMISSIONER. The |
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executive commissioner may adopt rules governing a health and human |
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services agency's response to reports and referrals from the |
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inspector general on issues identified by the inspector general |
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related to the agency or a contractor of the agency. |
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Sec. 531.477. ALLEGATIONS OF MISCONDUCT AGAINST PRESIDING |
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OFFICER. If a review by the inspector general involves allegations |
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that a presiding officer of a health and human services agency has |
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engaged in misconduct, the inspector general shall report to the |
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governor during the review until the report is completed or the |
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review is closed without a finding. |
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Sec. 531.478. PERIODIC REPORTING TO STATE AUDITOR AND |
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EXECUTIVE COMMISSIONER REQUIRED. The inspector general shall |
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timely inform the state auditor and the executive commissioner of |
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the initiation of a review of a health and human services agency |
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program and the ongoing status of each review. |
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Sec. 531.479. REPORTING OFFICE FINDINGS. The inspector |
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general shall report the findings of the office to: |
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(1) the executive commissioner; |
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(2) the governor; |
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(3) the lieutenant governor; |
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(4) the speaker of the house of representatives; |
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(5) the state auditor's office; and |
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(6) appropriate law enforcement and prosecutorial |
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agencies, including the office of the attorney general, if the |
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findings suggest the probability of criminal conduct. |
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Sec. 531.480. FLAGRANT VIOLATIONS; IMMEDIATE REPORT. The |
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inspector general shall immediately report to the executive |
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commissioner, the governor's general counsel, and the state auditor |
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a particularly serious or flagrant problem relating to the |
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administration of a program, operation of a health and human |
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services agency, or interference with an inspector general review. |
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Sec. 531.481. INFORMATION CONFIDENTIAL. (a) Except as |
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provided by this section, Sections 531.103, 531.477 through |
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531.480, and 531.482, all information and material compiled by the |
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inspector general during a review under this subchapter is: |
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(1) confidential and not subject to disclosure under |
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Chapter 552; and |
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(2) not subject to disclosure, discovery, subpoena, or |
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other means of legal compulsion for release to anyone other than the |
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state auditor's office, the commission, or the office or its agents |
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involved in the review related to that information or material. |
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(b) As the inspector general determines appropriate, |
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information relating to a review may be disclosed to: |
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(1) a law enforcement agency; |
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(2) the attorney general's office; |
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(3) the state auditor's office; or |
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(4) the commission. |
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(c) A person that receives information under Subsection (b) |
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may not disclose the information except to the extent that |
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disclosure is consistent with the authorized purpose for which the |
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person first obtained the information. |
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Sec. 531.482. DRAFT OF FINAL REVIEW REPORT; AGENCY |
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RESPONSE. (a) Except in cases in which the office has determined |
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that potential fraud exists, the office shall provide a draft of the |
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final review report of any investigation, audit, or review of the |
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operations of a health and human services agency to the presiding |
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officer of the agency before publishing the office's final review |
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report. |
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(b) The health and human services agency may provide a |
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response to the office's draft report in the manner prescribed by |
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the office not later than the 10th day after the date the draft |
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report is received by the agency. The inspector general by rule |
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shall specify the format and requirements of the agency response. |
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(c) Notwithstanding Subsection (a), the office may not |
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provide a draft report to the presiding officer of the agency if in |
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the inspector general's opinion providing the draft report could |
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negatively affect any anticipated civil or criminal proceedings. |
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(d) The office may include any portion of the agency's |
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response in the office's final report. |
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Sec. 531.483. FINAL REVIEW REPORTS; AGENCY RESPONSE. (a) |
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The inspector general shall prepare a final report for each review |
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conducted under this subchapter. The final report must include: |
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(1) a summary of the activities performed by the |
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inspector general in conducting the review; |
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(2) a determination of whether wrongdoing was found; |
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and |
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(3) a description of any findings of wrongdoing. |
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(b) The inspector general's final review reports are |
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subject to disclosure under Chapter 552. |
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(c) All working papers and other documents related to |
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compiling the final review reports remain confidential and are not |
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subject to disclosure under Chapter 552. |
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(d) Not later than the 60th day after the date the office |
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issues a final report that identifies deficiencies or |
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inefficiencies in, or recommends corrective measures in the |
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operations of, a health and human services agency, the agency shall |
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file a response that includes: |
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(1) an implementation plan and timeline for |
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implementing corrective measures; or |
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(2) the agency's rationale for declining to implement |
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corrective measures for the identified deficiencies or |
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inefficiencies or the office's recommended corrective measures, as |
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applicable. |
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Sec. 531.484. STATE AUDITOR AUDITS, INVESTIGATIONS, AND |
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ACCESS TO INFORMATION NOT IMPAIRED. This subchapter or other law |
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related to the operation of the inspector general does not prohibit |
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the state auditor from conducting an audit, investigation, or other |
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review or from having full and complete access to all records and |
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other information, including witnesses and electronic data, that |
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the state auditor considers necessary for the audit, investigation, |
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or other review. |
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Sec. 531.485. AUTHORITY OF STATE AUDITOR TO CONDUCT TIMELY |
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AUDITS NOT IMPAIRED. This chapter or other law related to the |
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operation of the inspector general does not take precedence over |
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the authority of the state auditor to conduct an audit under Chapter |
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321 or other law. |
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Sec. 531.486. BUDGET. (a) The inspector general shall |
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submit a budget in accordance with the reporting requirements of |
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the General Appropriations Act. |
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(b) The inspector general shall submit to the commission a |
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legislative appropriations request and an operating budget in |
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accordance with the service level agreement entered into under |
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Section 531.454 and applicable law. |
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(c) The commission shall submit the office's appropriations |
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request and, if required by or under law, operating budget to the |
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legislature. The request or budget is not subject to review, |
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alteration, or modification by the commission or executive |
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commissioner before submission to the legislature. |
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Sec. 531.487. COSTS. (a) The inspector general shall |
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maintain information regarding the cost of reviews. |
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(b) The inspector general may cooperate with appropriate |
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administrative and prosecutorial agencies, including the office of |
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the attorney general, in recovering costs incurred under this |
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subchapter from nongovernmental entities, including contractors or |
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individuals involved in: |
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(1) violations of applicable state or federal rules or |
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statutes; |
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(2) abusive or wilful misconduct; or |
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(3) violations of a provider contract or program |
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policy. |
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Sec. 531.488. ADMINISTRATIVE OR CIVIL PENALTY; INJUNCTION. |
|
(a) The office may: |
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(1) act for a health and human services agency in the |
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assessment by the office of administrative or civil penalties the |
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agency is authorized to assess under applicable law; and |
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(2) request that the attorney general obtain an |
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injunction to prevent a person from disposing of an asset |
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identified by the office as potentially subject to recovery by the |
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office due to the person's fraud, waste, or abuse. |
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(b) If the office imposes an administrative or civil penalty |
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under Subsection (a) for a health and human services agency: |
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(1) the health and human services agency may not |
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impose an administrative or civil penalty against the same person |
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for the same violation; and |
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(2) the office shall impose the penalty under |
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applicable rules of the office, this subchapter, and applicable |
|
laws governing the imposition of a penalty by the health and human |
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services agency. |
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SECTION 2. Section 531.001, Government Code, is amended by |
|
adding Subdivision (4-a) to read as follows: |
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(4-a) "Inspector general" means the inspector general |
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appointed under Subchapter M. |
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SECTION 3. Section 531.008(c), Government Code, is amended |
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to read as follows: |
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(c) The executive commissioner shall establish the |
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following divisions and offices within the commission: |
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(1) the eligibility services division to make |
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eligibility determinations for services provided through the |
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commission or a health and human services agency related to: |
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(A) the child health plan program; |
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(B) the financial assistance program under |
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Chapter 31, Human Resources Code; |
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(C) the medical assistance program under Chapter |
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32, Human Resources Code; |
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(D) the nutritional assistance programs under |
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Chapter 33, Human Resources Code; |
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(E) long-term care services, as defined by |
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Section 22.0011, Human Resources Code; |
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(F) community-based support services identified |
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or provided in accordance with Section 531.02481; and |
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(G) other health and human services programs, as |
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appropriate; |
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(2) [the office of inspector general to perform fraud
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and abuse investigation and enforcement functions as provided by
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Subchapter C and other law;
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[(3)] the office of the ombudsman to: |
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(A) provide dispute resolution services for the |
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commission and the health and human services agencies; and |
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(B) perform consumer protection functions |
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related to health and human services; |
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(3) [(4)] a purchasing division as provided by Section |
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531.017; and |
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(4) [(5)] an internal audit division to conduct a |
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program of internal auditing in accordance with [Government Code,] |
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Chapter 2102. |
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SECTION 4. Section 531.103(a), Government Code, is amended |
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to read as follows: |
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(a) The [commission, acting through the commission's] |
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office of inspector general[,] and the office of the attorney |
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general shall enter into a memorandum of understanding to develop |
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and implement joint written procedures for processing cases of |
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suspected fraud, waste, or abuse, as those terms are defined by |
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state or federal law, or other violations of state or federal law |
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under the state Medicaid program or other program administered by |
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the commission or a health and human services agency, including the |
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financial assistance program under Chapter 31, Human Resources |
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Code, a nutritional assistance program under Chapter 33, Human |
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Resources Code, and the child health plan program. The memorandum |
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of understanding shall require: |
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(1) the office of inspector general and the office of |
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the attorney general to set priorities and guidelines for referring |
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cases to appropriate state agencies for investigation, |
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prosecution, or other disposition to enhance deterrence of fraud, |
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waste, abuse, or other violations of state or federal law, |
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including a violation of Chapter 102, Occupations Code, in the |
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programs and maximize the imposition of penalties, the recovery of |
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money, and the successful prosecution of cases; |
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(1-a) the office of inspector general to refer each |
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case of suspected provider fraud, waste, or abuse to the office of |
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the attorney general not later than the 20th business day after the |
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date the office of inspector general determines that the existence |
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of fraud, waste, or abuse is reasonably indicated; |
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(1-b) the office of the attorney general to take |
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appropriate action in response to each case referred to the |
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attorney general, which action may include direct initiation of |
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prosecution, with the consent of the appropriate local district or |
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county attorney, direct initiation of civil litigation, referral to |
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an appropriate United States attorney, a district attorney, or a |
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county attorney, or referral to a collections agency for initiation |
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of civil litigation or other appropriate action; |
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(2) the office of inspector general to keep detailed |
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records for cases processed by that office or the office of the |
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attorney general, including information on the total number of |
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cases processed and, for each case: |
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(A) the agency and division to which the case is |
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referred for investigation; |
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(B) the date on which the case is referred; and |
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(C) the nature of the suspected fraud, waste, or |
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abuse; |
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(3) the office of inspector general to notify each |
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appropriate division of the office of the attorney general of each |
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case referred by the office of inspector general; |
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(4) the office of the attorney general to ensure that |
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information relating to each case investigated by that office is |
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available to each division of the office with responsibility for |
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investigating suspected fraud, waste, or abuse; |
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(5) the office of the attorney general to notify the |
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office of inspector general of each case the attorney general |
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declines to prosecute or prosecutes unsuccessfully; |
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(6) representatives of the office of inspector general |
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and of the office of the attorney general to meet not less than |
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quarterly to share case information and determine the appropriate |
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agency and division to investigate each case; and |
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(7) the office of inspector general and the office of |
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the attorney general to submit information requested by the |
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comptroller about each resolved case for the comptroller's use in |
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improving fraud detection. |
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SECTION 5. Sections 531.106(f) and (g), Government Code, |
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are amended to read as follows: |
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(f) The commission shall refer cases identified by the |
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technology to the [commission's] office of inspector general |
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[investigations and enforcement] or the office of the attorney |
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general, as appropriate. |
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(g) Each month, the learning or neural network technology |
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implemented under this section must match bureau of vital |
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statistics death records with Medicaid claims filed by a provider. |
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If the commission determines that a provider has filed a claim for |
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services provided to a person after the person's date of death, as |
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determined by the bureau of vital statistics death records, the |
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commission shall refer the case for investigation to the |
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[commission's] office of inspector general [investigations and
|
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enforcement]. |
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SECTION 6. Section 531.1061(a), Government Code, is amended |
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to read as follows: |
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(a) The office of inspector general [commission] shall use |
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an automated fraud investigation tracking system [through the
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commission's office of investigations and enforcement] to monitor |
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the progress of an investigation of suspected fraud, abuse, or |
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insufficient quality of care under the state Medicaid program. |
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SECTION 7. Sections 531.107(a) and (f), Government Code, |
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are amended to read as follows: |
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(a) The Medicaid and Public Assistance Fraud Oversight Task |
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Force advises and assists [the commission and] the [commission's] |
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office of inspector general [investigations and enforcement] in |
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improving the efficiency of fraud investigations and collections. |
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(f) At least once each fiscal quarter, the [commission's] |
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office of inspector general [investigations and enforcement] shall |
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provide to the task force: |
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(1) information detailing: |
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(A) the number of fraud referrals made to the |
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office and the origin of each referral; |
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(B) the time spent investigating each case; |
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(C) the number of cases investigated each month, |
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by program and region; |
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(D) the dollar value of each fraud case that |
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results in a criminal conviction; and |
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(E) the number of cases the office rejects and |
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the reason for rejection, by region; and |
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(2) any additional information the task force |
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requires. |
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SECTION 8. Section 531.108(a), Government Code, is amended |
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to read as follows: |
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(a) The [commission's] office of inspector general |
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[investigations and enforcement] shall compile and disseminate |
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accurate information and statistics relating to: |
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(1) fraud prevention; and |
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(2) post-fraud referrals received and accepted or |
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rejected from the [commission's] case management system of the |
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office of inspector general [or the case management system of a
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health and human services agency]. |
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SECTION 9. Sections 531.113(b) through (d), Government |
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Code, are amended to read as follows: |
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(b) Each managed care organization subject to this section |
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shall adopt a plan to prevent and reduce fraud and abuse and |
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annually file that plan with the [commission's] office of inspector |
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general for approval. The plan must include: |
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(1) a description of the managed care organization's |
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procedures for detecting and investigating possible acts of fraud |
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or abuse; |
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(2) a description of the managed care organization's |
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procedures for the mandatory reporting of possible acts of fraud or |
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abuse to the [commission's] office of inspector general; |
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(3) a description of the managed care organization's |
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procedures for educating and training personnel to prevent fraud |
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and abuse; |
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(4) the name, address, telephone number, and fax |
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number of the individual responsible for carrying out the plan; |
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(5) a description or chart outlining the |
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organizational arrangement of the managed care organization's |
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personnel responsible for investigating and reporting possible |
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acts of fraud or abuse; |
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(6) a detailed description of the results of |
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investigations of fraud and abuse conducted by the managed care |
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organization's special investigative unit or the entity with which |
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the managed care organization contracts under Subsection (a)(2); |
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and |
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(7) provisions for maintaining the confidentiality of |
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any patient information relevant to an investigation of fraud or |
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abuse. |
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(c) If a managed care organization contracts for the |
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investigation of fraudulent claims and other types of program abuse |
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by recipients and service providers under Subsection (a)(2), the |
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managed care organization shall file with the [commission's] office |
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of inspector general: |
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(1) a copy of the written contract; |
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(2) the names, addresses, telephone numbers, and fax |
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numbers of the principals of the entity with which the managed care |
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organization has contracted; and |
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(3) a description of the qualifications of the |
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principals of the entity with which the managed care organization |
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has contracted. |
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(d) The [commission's] office of inspector general may |
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review the records of a managed care organization to determine |
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compliance with this section. |
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SECTION 10. Section 533.001, Government Code, is amended by |
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adding Subdivision (3-a) to read as follows: |
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(3-a) "Inspector general" means the inspector general |
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appointed under Subchapter M, Chapter 531. |
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SECTION 11. Section 533.005(a), Government Code, is amended |
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to read as follows: |
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(a) A contract between a managed care organization and the |
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commission for the organization to provide health care services to |
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recipients must contain: |
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(1) procedures to ensure accountability to the state |
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for the provision of health care services, including procedures for |
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financial reporting, quality assurance, utilization review, and |
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assurance of contract and subcontract compliance; |
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(2) capitation rates that ensure the cost-effective |
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provision of quality health care; |
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(3) a requirement that the managed care organization |
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provide ready access to a person who assists recipients in |
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resolving issues relating to enrollment, plan administration, |
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education and training, access to services, and grievance |
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procedures; |
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(4) a requirement that the managed care organization |
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provide ready access to a person who assists providers in resolving |
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issues relating to payment, plan administration, education and |
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training, and grievance procedures; |
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(5) a requirement that the managed care organization |
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provide information and referral about the availability of |
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educational, social, and other community services that could |
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benefit a recipient; |
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(6) procedures for recipient outreach and education; |
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(7) a requirement that the managed care organization |
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make payment to a physician or provider for health care services |
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rendered to a recipient under a managed care plan not later than the |
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45th day after the date a claim for payment is received with |
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documentation reasonably necessary for the managed care |
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organization to process the claim, or within a period, not to exceed |
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60 days, specified by a written agreement between the physician or |
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provider and the managed care organization; |
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(8) a requirement that the commission, on the date of a |
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recipient's enrollment in a managed care plan issued by the managed |
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care organization, inform the organization of the recipient's |
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Medicaid certification date; |
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(9) a requirement that the managed care organization |
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comply with Section 533.006 as a condition of contract retention |
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and renewal; |
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(10) a requirement that the managed care organization |
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provide the information required by Section 533.012 and otherwise |
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comply and cooperate with the [commission's] office of inspector |
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general; |
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(11) a requirement that the managed care |
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organization's usages of out-of-network providers or groups of |
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out-of-network providers may not exceed limits for those usages |
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relating to total inpatient admissions, total outpatient services, |
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and emergency room admissions determined by the commission; |
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(12) if the commission finds that a managed care |
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organization has violated Subdivision (11), a requirement that the |
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managed care organization reimburse an out-of-network provider for |
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health care services at a rate that is equal to the allowable rate |
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for those services, as determined under Sections 32.028 and |
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32.0281, Human Resources Code; |
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(13) a requirement that the organization use advanced |
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practice nurses in addition to physicians as primary care providers |
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to increase the availability of primary care providers in the |
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organization's provider network; |
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(14) a requirement that the managed care organization |
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reimburse a federally qualified health center or rural health |
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clinic for health care services provided to a recipient outside of |
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regular business hours, including on a weekend day or holiday, at a |
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rate that is equal to the allowable rate for those services as |
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determined under Section 32.028, Human Resources Code, if the |
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recipient does not have a referral from the recipient's primary |
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care physician; and |
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(15) a requirement that the managed care organization |
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develop, implement, and maintain a system for tracking and |
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resolving all provider appeals related to claims payment, including |
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a process that will require: |
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(A) a tracking mechanism to document the status |
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and final disposition of each provider's claims payment appeal; |
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(B) the contracting with physicians who are not |
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network providers and who are of the same or related specialty as |
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the appealing physician to resolve claims disputes related to |
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denial on the basis of medical necessity that remain unresolved |
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subsequent to a provider appeal; and |
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(C) the determination of the physician resolving |
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the dispute to be binding on the managed care organization and |
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provider. |
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SECTION 12. Section 533.012(c), Government Code, is amended |
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to read as follows: |
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(c) The [commission's] office of inspector general |
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[investigations and enforcement] shall review the information |
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submitted under this section as appropriate in the investigation of |
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fraud in the Medicaid managed care program. The comptroller may |
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review the information in connection with the health care fraud |
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study conducted by the comptroller. |
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SECTION 13. Section 32.070(d), Human Resources Code, is |
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amended to read as follows: |
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(d) This section does not apply to a computerized audit |
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conducted using the Medicaid Fraud Detection Audit System or an |
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audit or investigation of fraud and abuse conducted by the Medicaid |
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fraud control unit of the office of the attorney general, the office |
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of the state auditor, the office of [the] inspector general |
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appointed under Subchapter M, Chapter 531, Government Code, or the |
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Office of Inspector General in the United States Department of |
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Health and Human Services. |
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SECTION 14. Section 33.015(e), Human Resources Code, is |
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amended to read as follows: |
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(e) The department shall require a person exempted under |
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this section from making a personal appearance at department |
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offices to provide verification of the person's entitlement to the |
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exemption on initial eligibility certification and on each |
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subsequent periodic eligibility recertification. If the person |
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does not provide verification and the department considers the |
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verification necessary to protect the integrity of the food stamp |
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program, the department shall initiate a fraud referral to the |
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[department's] office of inspector general appointed under |
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Subchapter M, Chapter 531, Government Code. |
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SECTION 15. Sections 531.102 and 531.1021, Government Code, |
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are repealed. |
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SECTION 16. (a) The repeal by this Act of Section 531.102, |
|
Government Code, does not affect the validity of a complaint, |
|
investigation, or other proceeding initiated under that section |
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before the effective date of this Act. A complaint, investigation, |
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or other proceeding initiated under that section is continued in |
|
accordance with the changes in law made by this Act. |
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(b) The repeal by this Act of Section 531.1021, Government |
|
Code, does not affect the validity of a subpoena issued under that |
|
section before the effective date of this Act. A subpoena issued |
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under that section before the effective date of this Act is governed |
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by the law that existed when the subpoena was issued, and the former |
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law is continued in effect for that purpose. |
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SECTION 17. (a) The person serving as inspector general |
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under Section 531.102(a-1), Government Code, on the effective date |
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of this Act shall serve as the inspector general appointed under |
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Subchapter M, Chapter 531, Government Code, as added by this Act, |
|
until February 1, 2009, and may be reappointed under Subchapter M, |
|
Chapter 531, if the person has the qualifications required under |
|
that subchapter. |
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(b) Not later than February 1, 2009, the governor shall |
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appoint an inspector general for the Office of the Inspector |
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General under Subchapter M, Chapter 531, Government Code, as added |
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by this Act, to a term expiring February 1, 2011. |
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SECTION 18. On the effective date of this Act: |
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(1) all functions, activities, employees, rules, |
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forms, money, property, contracts, memorandums of understanding, |
|
records, and obligations of the office of inspector general under |
|
Section 531.102(a-1), Government Code, become functions, |
|
activities, employees, rules, forms, money, property, contracts, |
|
memorandums of understanding, records, and obligations of the |
|
Office of the Inspector General appointed under Subchapter M, |
|
Chapter 531, Government Code, as added by this Act, without a change |
|
in status; and |
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(2) all money appropriated for the office of inspector |
|
general under Section 531.102(a-1), Government Code, including |
|
money for providing administrative support, is considered |
|
appropriated to the Office of the Inspector General appointed under |
|
Subchapter M, Chapter 531, Government Code, as added by this Act. |
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SECTION 19. This Act takes effect September 1, 2007. |