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A BILL TO BE ENTITLED
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AN ACT
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relating to the creation of the Office of State Inspector General. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle B, Title 4, Government Code, is amended |
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by adding Chapter 422 to read as follows: |
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CHAPTER 422. OFFICE OF STATE INSPECTOR GENERAL |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 422.001. DEFINITIONS. In this chapter: |
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(1) "Covered entity" means a person, entity, or |
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representative that has an employment, agency, contractual, |
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financial, or fiduciary relationship with a state agency that |
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administers or implements state or federally funded programs. The |
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term includes a provider. |
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(2) "Fraud" means an intentional deception or |
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misrepresentation made by a person with the knowledge that the |
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deception could result in some unauthorized benefit to that person |
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or some other person. The term includes any act that constitutes |
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fraud under applicable federal or state law. |
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(3) "Furnished," in reference to items or services: |
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(A) means items or services provided directly by, |
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provided under the direct supervision of, or ordered by: |
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(i) a practitioner or other individual, |
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either as an employee or in the individual's own capacity; |
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(ii) a covered entity; or |
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(iii) another supplier of services; and |
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(B) does not include services ordered by one |
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party but billed for and provided by or under the supervision of |
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another. |
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(4) "Hold on payment" means the temporary denial of |
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payment or reimbursement for items or services furnished by a |
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covered entity. The term includes the temporary denial of |
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reimbursement under a state or federal program for items or |
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services furnished by a specified provider. |
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(5) "Office" means the office of state inspector |
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general established under this chapter. |
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(6) "Practitioner" means a physician or other |
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individual licensed under state law to practice the individual's |
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profession. |
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(7) "Program exclusion" means the suspension of a |
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covered entity's authorization under a state or federal program to |
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request payment for, or reimbursement of, items or services |
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furnished by that entity. |
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(8) "Provider" means a person, firm, partnership, |
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corporation, agency, association, institution, or other entity |
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that was or is approved by the Health and Human Services Commission |
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to provide: |
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(A) medical assistance under contract or |
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provider agreement with the commission; or |
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(B) third-party billing vendor services under a |
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contract or provider agreement with the commission. |
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(9) "State inspector general" means the state |
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inspector general appointed under Section 422.052. |
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Sec. 422.002. APPLICATION OF SUNSET ACT. The office of |
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state inspector general is subject to Chapter 325 (Texas Sunset |
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Act). Unless continued in existence as provided by that chapter, |
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the office is abolished and this chapter expires September 1, 2019. |
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Sec. 422.003. REFERENCE IN OTHER STATUTES. Notwithstanding |
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any other provision of law, a reference in law or rule to the Health |
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and Human Services Commission's office of investigations and |
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enforcement or the Health and Human Services Commission's office of |
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inspector general means the office of state inspector general |
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established under this chapter. |
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[Sections 422.004-422.050 reserved for expansion] |
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SUBCHAPTER B. ADMINISTRATION AND COMPLAINTS |
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Sec. 422.051. OFFICE OF STATE INSPECTOR GENERAL. (a) The |
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office of state inspector general is an agency of this state. |
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(b) The office is under the direction and supervision of the |
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state inspector general. |
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(c) The office shall have its principal office and |
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headquarters in Austin. |
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Sec. 422.052. STATE INSPECTOR GENERAL: APPOINTMENT BY |
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GOVERNOR; QUALIFICATIONS. (a) The state inspector general is |
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appointed by the governor with the advice and consent of the senate. |
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(b) The appointment shall be made without regard to race, |
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color, disability, sex, religion, age, or national origin. |
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(c) In making the appointment, the governor shall consider |
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the person's knowledge of laws, experience in the enforcement of |
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law, honesty, integrity, education, training, and executive |
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ability. |
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Sec. 422.053. ELIGIBILITY. (a) A person is not eligible |
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for appointment as state inspector general if the person or the |
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person's spouse is an employee, officer, or paid consultant of a |
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trade association in a field under the office's jurisdiction. |
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(b) A person who is required to register as a lobbyist under |
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Chapter 305 because of the person's activities for compensation in |
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or on behalf of a profession related to a field under the office's |
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jurisdiction may not serve as state inspector general. |
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(c) A person is not eligible for appointment as state |
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inspector general if the person has a financial interest in a |
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corporation, organization, or association receiving state or |
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federal money under contract with this state or a political |
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subdivision of this state. |
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Sec. 422.054. TERM. The state inspector general serves a |
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two-year term expiring February 1 of each odd-numbered year. |
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Sec. 422.055. MERIT SYSTEM. (a) The office may establish |
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a merit system for its employees. |
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(b) The merit system may be maintained in conjunction with |
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other state agencies that are required by federal law to operate |
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under a merit system. |
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Sec. 422.056. PUBLIC INTEREST INFORMATION AND COMPLAINTS. |
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(a) The office shall develop and implement policies that provide |
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the public a reasonable opportunity to appear before the office and |
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to speak on any issue under the office's jurisdiction. |
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(b) The office shall prepare information of public interest |
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describing the functions of the office and the office's procedures |
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by which complaints are filed with and resolved by the office. The |
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office shall make the information available to the public and |
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appropriate state agencies. |
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(c) The office shall keep an information file about each |
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complaint filed with the office relating to a state agency, license |
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holder, or entity receiving state or federal money and falling |
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under the jurisdiction of the office. |
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Sec. 422.057. ANNUAL REPORT. (a) The state inspector |
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general annually shall prepare a complete and detailed written |
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report describing the activities of the office during the fiscal |
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year. The report must separately describe each major |
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investigation, audit, review, fraud prevention effort, and agency |
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assistance effort completed during the fiscal year. |
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(b) The annual report must meet the reporting requirements |
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applicable to financial reporting provided in the General |
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Appropriations Act. |
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(c) The state inspector general shall deliver a copy of each |
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annual report to: |
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(1) the governor; |
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(2) the lieutenant governor; |
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(3) the speaker of the house of representatives; |
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(4) the presiding officer of each house and senate |
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committee having jurisdiction over an agency to which this chapter |
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applies; |
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(5) the presiding officer of each agency to which this |
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chapter applies; and |
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(6) the comptroller. |
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(d) Each agency to which this chapter applies shall post the |
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annual report on its agency website. |
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(e) The state inspector general shall issue the annual |
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report not later than the 60th day after the last day of each fiscal |
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year. |
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[Sections 422.058-422.100 reserved for expansion] |
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SUBCHAPTER C. GENERAL POWERS AND DUTIES |
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Sec. 422.101. GENERAL RESPONSIBILITIES AND POWERS. |
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(a) The office is responsible for the audit, detection, |
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investigation, prevention, and review of fraud, waste, and abuse, |
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as defined in applicable state and federal law, in this state's |
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implementation or administration of all state or federally funded |
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programs, including health and human services programs provided |
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under Chapter 531, and in the enforcement of state law relating to |
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those programs. |
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(b) The office shall set clear objectives, priorities, and |
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performance standards for the office that 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 attorney general in accordance with this chapter. |
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(c) The office has all the powers necessary or appropriate |
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to carry out its responsibilities and functions under this chapter |
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and other law. |
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(d) The state inspector general shall establish policies |
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and procedures to guide the operation of the office and to ensure |
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that the work and practices of the office are in accordance with |
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commonly used and adopted professional standards related to the |
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fields of investigation and auditing in public administration |
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environments. |
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(e) An investigation, audit, or review conducted by the |
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office must conform to professional standards and best practices |
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for offices of inspectors general. |
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Sec. 422.102. RULEMAKING AUTHORITY. The state inspector |
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general may adopt rules necessary to implement this chapter and to |
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carry out the duties of the office under this chapter and other law. |
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Sec. 422.103. INFORMATION AND TECHNOLOGY. The office may |
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obtain any information or technology necessary to enable the office |
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to meet its responsibilities under this chapter or other law. |
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Sec. 422.104. OFFICE STAFF; TRAINING. The office shall |
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employ and train office staff to enable the staff to pursue fraud, |
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waste, and abuse cases as necessary. |
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Sec. 422.105. STATE AGENCY INSPECTORS GENERAL. (a) The |
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state inspector general, in consultation with the office of the |
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governor and as necessary to implement this chapter, may designate |
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persons to serve as agency inspectors general for state agencies |
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that implement or administer state or federally funded programs. A |
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state agency inspector general may be colocated with a state |
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agency. |
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(b) An agency inspector general shall report to and perform |
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duties as directed by the state inspector general. |
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(c) A state agency shall provide facilities and support |
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services including suitable office space, furniture, computer |
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equipment, communications equipment, and administrative support, |
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to each state agency inspector general colocated at the agency and |
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the state agency inspector general's staff. |
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(d) The office and each state agency that has a designated |
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state agency inspector general shall execute a service level |
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agreement to establish performance standards regarding the |
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facilities and support services provided by the agency. The |
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agreement must be reviewed at least annually to ensure that |
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facilities and support services are provided in accordance with the |
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agreement. |
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Sec. 422.106. PEACE OFFICERS. (a) The office may employ |
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and commission peace officers, in a number not to exceed 10 percent |
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of the total number of employees of the office, to assist the state |
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inspector general in carrying out the duties of the office under |
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this chapter or other law. |
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(b) A commissioned peace officer or other designated law |
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enforcement officer employed by the office is not entitled to |
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supplemental benefits from the law enforcement and custodial |
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officer supplemental retirement fund under Title 8. |
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Sec. 422.107. AWARD FOR REPORTING FRAUD, WASTE, ABUSE, OR |
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OVERCHARGES. (a) If the office determines that the report results |
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in the recovery of an administrative or civil penalty imposed by |
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law, the office may grant an award to an individual who reports: |
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(1) activity that constitutes fraud, waste, or abuse |
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of money related to any state or federally funded program |
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implemented or administered by a state agency; or |
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(2) overcharges in a program described by Subdivision |
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(1). |
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(b) The office may not grant an award to an individual in |
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connection with a report if the office or attorney general had |
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independent knowledge of the activity reported by the individual. |
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(c) The office shall determine the amount of an award |
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granted under this section. The amount may not exceed five percent |
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of the amount of the administrative or civil penalty imposed by law |
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that resulted from the individual's report. |
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(d) In determining the amount of an award granted under this |
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section, the office: |
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(1) shall consider the importance of the report in |
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ensuring the fiscal integrity of the program; and |
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(2) may consider whether the individual participated |
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in the reported fraud, waste, abuse, or overcharge. |
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(e) A person who brings an action under Subchapter C, |
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Chapter 36, Human Resources Code, is not eligible for an award under |
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this section. |
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Sec. 422.108. STATE AUDITOR AUDITS, INVESTIGATIONS, AND |
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ACCESS TO INFORMATION NOT IMPAIRED. This chapter or other law |
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related to the operation of the state inspector general or a state |
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agency inspector general does not prohibit the state auditor from |
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conducting an audit, investigation, or other review or from having |
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full and complete access to all records and other information, |
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including witnesses and electronic data, that the state auditor |
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considers necessary for the audit, investigation, or other review. |
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Sec. 422.109. 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 state inspector general or a state agency |
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inspector general does not take precedence over the authority of |
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the state auditor to conduct an audit under Chapter 321 or other |
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law. |
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[Sections 422.110-422.150 reserved for expansion] |
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SUBCHAPTER D. INVESTIGATIONS AND ENFORCEMENT ACTIONS |
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Sec. 422.151. AGENCY COOPERATION. Each state agency shall |
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provide assistance as necessary for the office to perform the |
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office's duties relating to the investigation of fraud, waste, and |
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abuse in the implementation or administration of state or federally |
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funded programs. The office is entitled to access any information |
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maintained by a state agency or by any covered entity, including |
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internal records, relevant to the functions of the office. |
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Sec. 422.152. CRITERIA FOR INVESTIGATIONS. The office by |
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rule shall set specific criteria, including claims criteria, that |
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when met require the office to begin an investigation. |
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Sec. 422.153. INTEGRITY REVIEWS. (a) If the office |
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receives a complaint of fraud, waste, or abuse from any source, the |
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office shall conduct an integrity review to determine whether there |
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is sufficient basis to warrant a full investigation. |
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(b) The office shall begin the integrity review not later |
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than the 30th day after the date the office receives a complaint or |
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has reason to believe that fraud, waste, or abuse has occurred. An |
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integrity review must be completed not later than the 90th day after |
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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 fraud, waste, or abuse involving possible |
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criminal conduct has occurred in the administration or |
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implementation of a state or federally funded program, the office |
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shall take the following action: |
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(1) if a covered entity is suspected of fraud, waste, |
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or abuse involving criminal conduct, the office shall refer the |
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case to the appropriate state or local official having jurisdiction |
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to prosecute the criminal conduct; or |
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(2) if there is reason to believe that a recipient has |
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defrauded a federally funded program, the office may conduct a full |
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investigation of the suspected fraud. |
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(d) A criminal referral by the office does not preclude the |
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office from continuing its investigation of the covered entity and |
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imposing appropriate administrative or civil penalties. |
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Sec. 422.154. WITHHELD, CONCEALED, OR DESTROYED RECORDS; |
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HOLD ON PAYMENT OF CLAIMS. (a) If the office learns or has reason |
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to suspect that a covered entity's records 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 appropriate state or |
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local official having jurisdiction to prosecute criminal conduct. |
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(b) A criminal referral by the office does not preclude the |
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office from continuing its investigation of the covered entity and |
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imposing appropriate administrative or civil penalties. |
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(c) In addition to any hold on payment of claims authorized |
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under other state or federal law, the office shall impose, without |
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prior notice, a hold on payment of money owed or claimed to be owed, |
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including a claim for reimbursement, submitted to a state agency by |
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a covered entity: |
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(1) to compel production of records; or |
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(2) on request by the appropriate state or local |
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official having jurisdiction to prosecute a case under this |
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section. |
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(d) The office shall notify the covered entity of the hold |
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not later than the fifth working day after the date the hold is |
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imposed. |
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Sec. 422.155. ADMINISTRATIVE HEARING ON PAYMENT CLAIM HOLD. |
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(a) On timely written request by a covered entity subject to a hold |
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on payment of claims under Section 422.154, other than a hold |
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requested under that section by an appropriate state or local |
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official having jurisdiction to prosecute, 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 state inspector general shall adopt rules that allow |
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a covered entity subject to a hold under Section 422.154, other than |
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a hold requested under that section by the appropriate state or |
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local official having jurisdiction to prosecute, to seek an |
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informal resolution of the issues identified by the office in the |
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notice provided by the office. |
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(c) A covered entity subject to a hold shall seek an |
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expedited hearing under Subsection (a) or an informal resolution |
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under Subsection (b) not later than the 10th day after the date the |
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entity receives notice of the hold from the office. |
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(d) A covered entity's decision to seek an informal |
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resolution under Subsection (b) does not extend the time by which |
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the entity must request an expedited administrative hearing under |
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Subsection (a). An expedited hearing initiated under Subsection |
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(a) shall be stayed at the office's request until the informal |
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resolution process is completed. |
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Sec. 422.156. GUIDELINES FOR IMPOSING PAYMENT CLAIM HOLDS |
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OR PROGRAM EXCLUSIONS. The office shall establish guidelines under |
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which holds on payment of claims or program exclusions: |
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(1) may discretionally be imposed on a covered entity; |
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or |
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(2) shall automatically be imposed on a covered |
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entity. |
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Sec. 422.157. ASSESSMENT OF ADMINISTRATIVE PENALTIES; |
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INJUNCTIONS; AUDITS AND INVESTIGATIONS. In addition to performing |
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functions and duties otherwise provided by law, the office may: |
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(1) assess administrative penalties authorized by law |
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on behalf of the state agency implementing or administering the |
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state or federally funded program and retain from amounts collected |
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money sufficient to cover investigative and collection costs; |
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(2) request the attorney general to 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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(3) provide for coordination between the office and |
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special investigative units formed by managed care organizations |
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under Section 531.113 or entities with which managed care |
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organizations contract under that section; |
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(4) audit the use and effectiveness of state or |
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federal money, including contract and grant money, administered by |
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a person or state agency receiving the money from a state agency; |
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(5) conduct reviews, investigations, and inspections |
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relating to the money described by Subdivision (4); |
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(6) recommend policies promoting economical and |
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efficient administration of the money described by Subdivision (4) |
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and the prevention and detection of fraud, waste, and abuse in the |
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administration of that money; and |
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(7) conduct internal affairs investigations in |
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instances of fraud, waste, and abuse and in instances of misconduct |
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by employees, contractors, subcontractors, and vendors. |
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Sec. 422.158. FINAL REPORTS; CONFIDENTIALITY. (a) The |
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office shall prepare a final report on each audit or investigation |
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conducted under this chapter. The final report must include: |
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(1) a summary of the activities performed by the |
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office in conducting the audit or investigation; |
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(2) a statement regarding whether the audit or |
|
investigation resulted in a finding of any wrongdoing; and |
|
(3) a description of any finding of wrongdoing. |
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(b) A final report on an audit or investigation is subject |
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to required disclosure under Chapter 552. All information and |
|
material compiled during the audit or investigation remains |
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confidential and is not subject to disclosure, except as provided |
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by Section 422.162. |
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(c) Unless otherwise prohibited by this chapter or other |
|
law, the state inspector general shall deliver a copy of each final |
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report that concerns the implementation or administration of a |
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state or federally funded program to: |
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(1) the presiding officer of the subject agency; |
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(2) the governor; |
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(3) the lieutenant governor; and |
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(4) the speaker of the house of representatives. |
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Sec. 422.159. AGENCY RESPONSE. (a) Not later than the |
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60th day after the date a state inspector general or state agency |
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inspector general report that identifies deficiencies or |
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recommends specified corrective measures in the operations of a |
|
state agency is issued, the agency shall file with the office a |
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response that includes: |
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(1) an implementation plan and timeline for |
|
implementing corrective measures; or |
|
(2) the agency's rationale for declining to implement |
|
corrective measures for the identified deficiencies or to implement |
|
the state inspector general's or state agency inspector general's |
|
recommended corrective measures. |
|
(b) The office by rule shall specify the format and |
|
requirements of a state agency response. |
|
(c) A state agency to which this chapter applies shall adopt |
|
rules to respond to reports and recommendations from the state |
|
inspector general or a state agency inspector general. |
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Sec. 422.160. FRAUD PREVENTION INFORMATION. (a) The |
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office shall compile and disseminate 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 |
|
rejected from the office's case management system or the case |
|
management system of a state agency. |
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(b) The office shall: |
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(1) aggressively publicize successful fraud |
|
prosecutions and fraud-prevention programs through all available |
|
means, including the use of statewide press releases; and |
|
(2) maintain and promote a toll-free hotline for |
|
reporting suspected fraud in state or federally funded programs |
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implemented or administered by an agency. |
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Sec. 422.161. ADMINISTRATIVE SUBPOENA. (a) The office may |
|
issue an administrative subpoena in connection with an |
|
investigation conducted by the office 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 reimbursement of the expenses of a witness whose |
|
attendance is compelled under this section is governed by Section |
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2001.103. |
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Sec. 422.162. CONFIDENTIALITY. (a) Information and |
|
material subpoenaed or compiled by the office in connection with an |
|
audit or investigation is confidential and not subject to |
|
disclosure under Chapter 552. The information and material is not |
|
subject to disclosure, discovery, subpoena, or other means of legal |
|
compulsion for release to anyone other than the office or its |
|
employees or agents involved in the audit or investigation |
|
conducted by the office, except that the information may be |
|
disclosed to the attorney general, the state auditor's office, and |
|
law enforcement agencies. |
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(b) A person who receives information under Subsection (a) |
|
may disclose the information only in accordance with Subsection (a) |
|
and in a manner that is consistent with the authorized purpose for |
|
which the person received the information. |
|
Sec. 422.163. INTERAGENCY COORDINATION. (a) The office |
|
and 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 any state or federally funded program |
|
implemented or administered by a state agency. |
|
(b) The memorandum of understanding must require: |
|
(1) the office and 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, abuse, or other violations of |
|
state or federal law, including a violation of Chapter 102, |
|
Occupations Code, in the programs and maximize the imposition of |
|
penalties, the recovery of money, and the successful prosecution of |
|
cases; |
|
(2) the office to refer each case of suspected covered |
|
entity fraud, waste, or abuse to the attorney general not later than |
|
the 20th business day after the date the office determines that the |
|
existence of fraud, waste, or abuse is reasonably indicated; |
|
(3) the attorney general to take appropriate action in |
|
response to each case referred to the attorney general, including |
|
the direct initiation of prosecution with the consent of the |
|
appropriate local district or county attorney, direct initiation of |
|
civil litigation, referral to an appropriate United States |
|
attorney, district attorney, or county attorney, and referral to a |
|
collections agency for initiation of civil litigation or other |
|
appropriate action; |
|
(4) the office to keep detailed records for cases |
|
processed by the office or 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; |
|
(5) the office to notify each appropriate division of |
|
the attorney general's office of each case referred by the office; |
|
(6) the attorney general to ensure that information |
|
relating to each case investigated by the attorney general is |
|
available to each division of the attorney general's office with |
|
responsibility for investigating suspected fraud, waste, or abuse; |
|
(7) the attorney general to notify the office of each |
|
case the attorney general declines to prosecute or prosecutes |
|
unsuccessfully; |
|
(8) representatives of the office and 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 |
|
(9) the office and the attorney general to submit |
|
information requested by the comptroller about each resolved case |
|
for the comptroller's use in improving fraud detection. |
|
(c) With respect to Medicaid fraud, in addition to the |
|
requirements under Subsection (b), the memorandum of understanding |
|
must: |
|
(1) ensure that 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 not imposed; and |
|
(2) include procedures to facilitate the referral of |
|
cases directly to the attorney general. |
|
Sec. 422.164. EXCHANGE OF INFORMATION. An exchange of |
|
information under this subchapter between the attorney general and |
|
the office or any other state agency does not affect whether the |
|
information is subject to disclosure under Chapter 552. |
|
Sec. 422.165. SEMIANNUAL REPORT. (a) The office and the |
|
attorney general shall jointly prepare and submit a semiannual |
|
report to the governor, lieutenant governor, speaker of the house |
|
of representatives, state auditor, and comptroller on: |
|
(1) the activities of the attorney general and the |
|
office in detecting and preventing fraud, waste, and abuse under |
|
any state or federally funded program implemented or administered |
|
by a state agency that is reviewed by the office under this chapter; |
|
and |
|
(2) the activities of the office during the fiscal |
|
year, including separate descriptions of each major investigation, |
|
audit, review, fraud prevention effort, and agency assistance |
|
effort completed during the fiscal year. |
|
(b) The report may be consolidated with any other report |
|
relating to the same subject matter the office or the attorney |
|
general is required to submit under other law. |
|
Sec. 422.166. ASSESSMENT AND COLLECTION OF CERTAIN FEES AND |
|
COSTS. (a) The office and the attorney general may not assess or |
|
collect investigation or attorney's fees on behalf of any state |
|
agency unless the attorney general or other state agency collects a |
|
penalty, restitution, or other reimbursement payment to this state. |
|
(b) A district attorney, county attorney, municipal |
|
attorney, or private collection agency may collect and retain: |
|
(1) costs associated with a case referred to the |
|
government attorney or private collection agency in accordance with |
|
procedures adopted under this section; and |
|
(2) 20 percent of the amount of the penalty, |
|
restitution, or other reimbursement payment collected. |
|
Sec. 422.167. ASSISTING INVESTIGATIONS BY ATTORNEY |
|
GENERAL. (a) The office and the attorney general shall execute a |
|
memorandum of understanding under which the office shall provide |
|
investigative support, as required, to the attorney general in |
|
connection with cases under Subchapter B, Chapter 36, Human |
|
Resources Code. Under the memorandum of understanding, the office |
|
shall assist in performing preliminary investigations and ongoing |
|
investigations for actions involving the attorney general under |
|
Chapter 36, Human Resources Code. |
|
(b) The memorandum of understanding must: |
|
(1) specify the type, scope, and format of the |
|
investigative support provided to the attorney general under this |
|
section; and |
|
(2) ensure that barriers to direct fraud referrals to |
|
the state's Medicaid fraud control unit by Medicaid agencies or |
|
unreasonable impediments to communication between Medicaid agency |
|
employees and this state's Medicaid fraud control unit are not |
|
imposed. |
|
Sec. 422.168. COOPERATION AND COORDINATION WITH STATE |
|
AUDITOR. (a) The state auditor may, on request of the state |
|
inspector general or a state agency inspector general, provide |
|
appropriate information or other assistance to the state inspector |
|
general or office, as determined by the state auditor. |
|
(b) The state inspector general or a state agency inspector |
|
general may meet with the state auditor's office to coordinate a |
|
review conducted under this subchapter, share information, or |
|
schedule work plans. |
|
(c) The state auditor is entitled to access all information |
|
maintained by the state inspector general or a state agency |
|
inspector general, including vouchers, electronic data, internal |
|
records, and information obtained from a state agency or covered |
|
entity subject to Section 422.162. |
|
(d) Any information obtained or provided by the state |
|
auditor under this section is confidential and not subject to |
|
disclosure under Chapter 552. |
|
Sec. 422.169. PERIODIC REPORTING TO STATE AUDITOR AND |
|
GOVERNOR REQUIRED. The state inspector general shall timely inform |
|
the state auditor and the governor of the initiation of a review of |
|
a state agency program by the state inspector general or a state |
|
agency inspector general and the ongoing status of each review by |
|
the state inspector general or a state agency inspector general. |
|
Sec. 422.170. FLAGRANT VIOLATIONS; IMMEDIATE REPORT. The |
|
state inspector general or a state agency inspector general shall |
|
immediately report to the governor's general counsel and the state |
|
auditor a particularly serious or flagrant problem relating to the |
|
administration of a program, operation of a state agency program, |
|
or interference with a review by the state inspector general or a |
|
state agency inspector general. |
|
SECTION 2. Section 531.001, Government Code, is amended by |
|
adding Subdivision (4-a) to read as follows: |
|
(4-a) "Office of state inspector general" means the |
|
office of state inspector general established under Chapter 422. |
|
SECTION 3. Subsection (c), Section 531.008, Government |
|
Code, is amended to read as follows: |
|
(c) The executive commissioner shall establish the |
|
following divisions and offices within the commission: |
|
(1) the eligibility services division to make |
|
eligibility determinations for services provided through the |
|
commission or a health and human services agency related to: |
|
(A) the child health plan program; |
|
(B) the financial assistance program under |
|
Chapter 31, Human Resources Code; |
|
(C) the medical assistance program under Chapter |
|
32, Human Resources Code; |
|
(D) the nutritional assistance programs under |
|
Chapter 33, Human Resources Code; |
|
(E) long-term care services, as defined by |
|
Section 22.0011, Human Resources Code; |
|
(F) community-based support services identified |
|
or provided in accordance with Section 531.02481; and |
|
(G) other health and human services programs, as |
|
appropriate; |
|
(2) [the office of inspector general to perform fraud
|
|
and abuse investigation and enforcement functions as provided by
|
|
Subchapter C and other law;
|
|
[(3)] the office of the ombudsman to: |
|
(A) provide dispute resolution services for the |
|
commission and the health and human services agencies; and |
|
(B) perform consumer protection functions |
|
related to health and human services; |
|
(3) [(4)] a purchasing division as provided by Section |
|
531.017; and |
|
(4) [(5)] an internal audit division to conduct a |
|
program of internal auditing in accordance with [Government Code,] |
|
Chapter 2102. |
|
SECTION 4. Section 531.105, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.105. FRAUD DETECTION TRAINING. (a) The office of |
|
state inspector general [commission] shall develop and implement a |
|
program to provide annual training to contractors who process |
|
Medicaid claims and appropriate staff of the commission and other |
|
health and human services agencies [the Texas Department of Health
|
|
and the Texas Department of Human Services] in identifying |
|
potential cases of fraud, waste, or abuse under the state Medicaid |
|
program. The training provided to the contractors and staff must |
|
include clear criteria that specify: |
|
(1) the circumstances under which a person should |
|
refer a potential case to the office [commission]; and |
|
(2) the time by which a referral should be made. |
|
(b) The commission and other health and human services |
|
agencies [The Texas Department of Health and the Texas Department
|
|
of Human Services], in cooperation with the office of state |
|
inspector general [commission], shall periodically set a goal of |
|
the number of potential cases of fraud, waste, or abuse under the |
|
state Medicaid program that each agency will attempt to identify |
|
and refer to the office [commission]. The office [commission] |
|
shall include information on the agencies' goals and the success of |
|
each agency in meeting the agency's goal in the report required by |
|
Section 422.165 [531.103(c)]. |
|
SECTION 5. Subsections (a), (b), and (d) through (g), |
|
Sections 531.106, Government Code, are amended to read as follows: |
|
(a) The office of state inspector general [commission] |
|
shall use learning or neural network technology to identify and |
|
deter fraud in the Medicaid program throughout this state. |
|
(b) The office of state inspector general [commission] |
|
shall contract with a private or public entity to develop and |
|
implement the technology. The office [commission] may require the |
|
entity it contracts with to install and operate the technology at |
|
locations specified by the office [commission], including the |
|
office of state inspector general's [commission] offices. |
|
(d) The office of state inspector general [commission] |
|
shall require each health and human services agency that performs |
|
any aspect of the state Medicaid program to participate in the |
|
implementation and use of the technology. |
|
(e) The office of state inspector general [commission] |
|
shall maintain all information necessary to apply the technology to |
|
claims data covering a period of at least two years. |
|
(f) The office of state inspector general [commission] |
|
shall investigate [refer] cases identified by the technology and |
|
shall refer cases to the [commission's office of investigations and
|
|
enforcement or the office of the] attorney general for prosecution, |
|
as appropriate. |
|
(g) Each month, the learning or neural network technology |
|
implemented under this section must match bureau of vital |
|
statistics death records with Medicaid claims filed by a provider. |
|
If the office of state inspector general [commission] determines |
|
that a provider has filed a claim for services provided to a person |
|
after the person's date of death, as determined by the bureau of |
|
vital statistics death records, the office [commission] shall |
|
investigate [refer] the case [for investigation to the commission's
|
|
office of investigations and enforcement]. |
|
SECTION 6. Section 531.1061, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.1061. FRAUD INVESTIGATION TRACKING SYSTEM. |
|
(a) The office of state inspector general [commission] shall use |
|
an automated fraud investigation tracking system [through the
|
|
commission's office of investigations and enforcement] to monitor |
|
the progress of an investigation of suspected fraud, waste, abuse, |
|
or insufficient quality of care under the state Medicaid program. |
|
(b) For each case of suspected fraud, waste, abuse, or |
|
insufficient quality of care identified by the learning or neural |
|
network technology required under Section 531.106, the automated |
|
fraud investigation tracking system must: |
|
(1) receive electronically transferred records |
|
relating to the identified case from the learning or neural network |
|
technology; |
|
(2) record the details and monitor the status of an |
|
investigation of the identified case, including maintaining a |
|
record of the beginning and completion dates for each phase of the |
|
case investigation; |
|
(3) generate documents and reports related to the |
|
status of the case investigation; and |
|
(4) generate standard letters to a provider regarding |
|
the status or outcome of an investigation. |
|
(c) The office of state inspector general [commission] |
|
shall require each health and human services agency that performs |
|
any aspect of the state Medicaid program to participate in the |
|
implementation and use of the automated fraud investigation |
|
tracking system. |
|
SECTION 7. Subsection (a), Section 531.1062, Government |
|
Code, is amended to read as follows: |
|
(a) The office of state inspector general [commission] |
|
shall use an automated recovery monitoring system to monitor the |
|
collections process for a settled case of fraud, waste, abuse, or |
|
insufficient quality of care under the state Medicaid program. |
|
SECTION 8. Subsections (a), (b), and (f), Section 531.107, |
|
Government Code, are amended to read as follows: |
|
(a) The Medicaid and Public Assistance Fraud Oversight Task |
|
Force advises and assists the [commission and the commission's] |
|
office of state inspector general [of investigations and
|
|
enforcement] in improving the efficiency of fraud investigations |
|
and collections. |
|
(b) The task force is composed of a representative of the: |
|
(1) attorney general's office, appointed by the |
|
attorney general; |
|
(2) comptroller's office, appointed by the |
|
comptroller; |
|
(3) Department of Public Safety, appointed by the |
|
public safety director; |
|
(4) state auditor's office, appointed by the state |
|
auditor; |
|
(5) office of state inspector general, appointed by |
|
the state inspector general [commission, appointed by the
|
|
commissioner of health and human services]; |
|
(6) [Texas] Department of Aging and Disability [Human] |
|
Services, appointed by the commissioner of aging and disability |
|
[human] services; |
|
(7) Texas Department of Insurance, appointed by the |
|
commissioner of insurance; and |
|
(8) [Texas] Department of State Health Services, |
|
appointed by the commissioner of state [public] health services. |
|
(f) At least once each fiscal quarter, the [commission's] |
|
office of state inspector general [of investigations and
|
|
enforcement] shall provide to the task force: |
|
(1) information detailing: |
|
(A) the number of fraud referrals made to the |
|
office and the origin of each referral; |
|
(B) the time spent investigating each case; |
|
(C) the number of cases investigated each month, |
|
by program and region; |
|
(D) the dollar value of each fraud case that |
|
results in a criminal conviction; and |
|
(E) the number of cases the office rejects and |
|
the reason for rejection, by region; and |
|
(2) any additional information the task force |
|
requires. |
|
SECTION 9. Section 531.108, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.108. FRAUD PREVENTION. (a) [The commission's
|
|
office of investigations and enforcement shall compile and
|
|
disseminate accurate information and statistics relating to:
|
|
[(1) fraud prevention; and
|
|
[(2)
post-fraud referrals received and accepted or
|
|
rejected from the commission's case management system or the case
|
|
management system of a health and human services agency.
|
|
[(b) The commission shall:
|
|
[(1)
aggressively publicize successful fraud
|
|
prosecutions and fraud-prevention programs through all available
|
|
means, including the use of statewide press releases issued in
|
|
coordination with the Texas Department of Human Services; and
|
|
[(2)
ensure that a toll-free hotline for reporting
|
|
suspected fraud in programs administered by the commission or a
|
|
health and human services agency is maintained and promoted, either
|
|
by the commission or by a health and human services agency.
|
|
[(c)] The office of state inspector general [commission] |
|
shall develop a cost-effective method of identifying applicants for |
|
public assistance in counties bordering other states and in |
|
metropolitan areas selected by the office [commission] who are |
|
already receiving benefits in other states. If economically |
|
feasible, the office [commission] may develop a computerized |
|
matching system. |
|
(b) [(d)] The office of state inspector general |
|
[commission] shall: |
|
(1) verify automobile information that is used as |
|
criteria for eligibility; and |
|
(2) establish a computerized matching system with the |
|
Texas Department of Criminal Justice to prevent an incarcerated |
|
individual from illegally receiving public assistance benefits |
|
administered by the commission. |
|
(c) [(e)] The office of state inspector general |
|
[commission] shall submit to the governor and Legislative Budget |
|
Board a semiannual report on the results of computerized matching |
|
of office [commission] information with information from |
|
neighboring states, if any, and information from the Texas |
|
Department of Criminal Justice. The report may be consolidated |
|
with any other report relating to the same subject matter the office |
|
[commission] is required to submit under other law. |
|
SECTION 10. Section 531.109, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.109. SELECTION AND REVIEW OF CLAIMS. (a) The |
|
office of state inspector general [commission] shall annually |
|
select and review a random, statistically valid sample of all |
|
claims for reimbursement under the state Medicaid program, |
|
including the vendor drug program, for potential cases of fraud, |
|
waste, or abuse. |
|
(b) In conducting the annual review of claims under |
|
Subsection (a), the office of state inspector general [commission] |
|
may directly contact a recipient by telephone or in person, or both, |
|
to verify that the services for which a claim for reimbursement was |
|
submitted by a provider were actually provided to the recipient. |
|
(c) Based on the results of the annual review of claims, the |
|
office of state inspector general [commission] shall determine the |
|
types of claims at which office [commission] resources for fraud, |
|
waste, and abuse detection should be primarily directed. |
|
SECTION 11. Subsections (a) and (c) through (f), Section |
|
531.110, Government Code, are amended to read as follows: |
|
(a) The office of state inspector general [commission] |
|
shall conduct electronic data matches for a recipient of assistance |
|
under the state Medicaid program at least quarterly to verify the |
|
identity, income, employment status, and other factors that affect |
|
the eligibility of the recipient. |
|
(c) The commission and other health and human services |
|
agencies [Texas Department of Human Services] shall cooperate with |
|
the office of state inspector general [commission] by providing |
|
data or any other assistance necessary to conduct the electronic |
|
data matches required by this section. |
|
(d) The office of state inspector general [commission] may |
|
contract with a public or private entity to conduct the electronic |
|
data matches required by this section. |
|
(e) The office of state inspector general [commission, or a
|
|
health and human services agency designated by the commission,] by |
|
rule shall establish procedures to verify the electronic data |
|
matches conducted by the office [commission] under this section. |
|
Not later than the 20th day after the date the electronic data match |
|
is verified, the commission and other health and human services |
|
agencies [Texas Department of Human Services] shall remove from |
|
eligibility a recipient who is determined to be ineligible for |
|
assistance under the state Medicaid program. |
|
(f) The office of state inspector general [commission] |
|
shall report biennially to the legislature the results of the |
|
electronic data matching program. The report must include a |
|
summary of the number of applicants who were removed from |
|
eligibility for assistance under the state Medicaid program as a |
|
result of an electronic data match conducted under this section. |
|
SECTION 12. Section 531.111, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.111. FRAUD DETECTION TECHNOLOGY. The office of |
|
state inspector general [commission] may contract with a contractor |
|
who specializes in developing technology capable of identifying |
|
patterns of fraud exhibited by Medicaid recipients to: |
|
(1) develop and implement the fraud detection |
|
technology; and |
|
(2) determine if a pattern of fraud by Medicaid |
|
recipients is present in the recipients' eligibility files |
|
maintained by the commission and other health and human services |
|
agencies [Texas Department of Human Services]. |
|
SECTION 13. Section 531.113, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.113. MANAGED CARE ORGANIZATIONS: SPECIAL |
|
INVESTIGATIVE UNITS OR CONTRACTS. (a) Each managed care |
|
organization that provides or arranges for the provision of health |
|
care services to an individual under a government-funded program, |
|
including the Medicaid program and the child health plan program, |
|
shall: |
|
(1) establish and maintain a special investigative |
|
unit within the managed care organization to investigate fraudulent |
|
claims and other types of program waste or abuse by recipients and |
|
service providers; or |
|
(2) contract with another entity for the investigation |
|
of fraudulent claims and other types of program waste or abuse by |
|
recipients and service providers. |
|
(b) Each managed care organization subject to this section |
|
shall adopt a plan to prevent and reduce fraud, waste, and abuse and |
|
annually file that plan with the [commission's] office of inspector |
|
general for approval. The plan must include: |
|
(1) a description of the managed care organization's |
|
procedures for detecting and investigating possible acts of fraud, |
|
waste, or abuse; |
|
(2) a description of the managed care organization's |
|
procedures for the mandatory reporting of possible acts of fraud, |
|
waste, or abuse to the [commission's] office of inspector general; |
|
(3) a description of the managed care organization's |
|
procedures for educating and training personnel to prevent fraud, |
|
waste, and abuse; |
|
(4) the name, address, telephone number, and fax |
|
number of the individual responsible for carrying out the plan; |
|
(5) a description or chart outlining the |
|
organizational arrangement of the managed care organization's |
|
personnel responsible for investigating and reporting possible |
|
acts of fraud, waste, or abuse; |
|
(6) a detailed description of the results of |
|
investigations of fraud, waste, and abuse conducted by the managed |
|
care organization's special investigative unit or the entity with |
|
which the managed care organization contracts under Subsection |
|
(a)(2); and |
|
(7) provisions for maintaining the confidentiality of |
|
any patient information relevant to an investigation of fraud, |
|
waste, or abuse. |
|
(c) If a managed care organization contracts for the |
|
investigation of fraudulent claims and other types of program waste |
|
or abuse by recipients and service providers under Subsection |
|
(a)(2), the managed care organization shall file with the |
|
[commission's] office of inspector general: |
|
(1) a copy of the written contract; |
|
(2) the names, addresses, telephone numbers, and fax |
|
numbers of the principals of the entity with which the managed care |
|
organization has contracted; and |
|
(3) a description of the qualifications of the |
|
principals of the entity with which the managed care organization |
|
has contracted. |
|
(d) The [commission's] office of inspector general may |
|
review the records of a managed care organization to determine |
|
compliance with this section. |
|
(e) The state inspector general [commissioner] shall adopt |
|
rules as necessary to accomplish the purposes of this section. |
|
SECTION 14. Subsections (b) and (g), Section 531.114, |
|
Government Code, are amended to read as follows: |
|
(b) If after an investigation the office of state inspector |
|
general [commission] determines that a person violated Subsection |
|
(a), the office [commission] shall: |
|
(1) notify the person of the alleged violation not |
|
later than the 30th day after the date the office [commission] |
|
completes the investigation and provide the person with an |
|
opportunity for a hearing on the matter; or |
|
(2) refer the matter to the appropriate prosecuting |
|
attorney for prosecution. |
|
(g) The office of state inspector general [commission] |
|
shall adopt rules as necessary to implement this section. |
|
SECTION 15. Section 533.001, Government Code, is amended by |
|
adding Subdivision (8) to read as follows: |
|
(8) "State inspector general" means the state |
|
inspector general appointed under Chapter 422. |
|
SECTION 16. Subsection (a), Section 533.005, Government |
|
Code, is amended to read as follows: |
|
(a) A contract between a managed care organization and the |
|
commission for the organization to provide health care services to |
|
recipients must contain: |
|
(1) procedures to ensure accountability to the state |
|
for the provision of health care services, including procedures for |
|
financial reporting, quality assurance, utilization review, and |
|
assurance of contract and subcontract compliance; |
|
(2) capitation rates that ensure the cost-effective |
|
provision of quality health care; |
|
(3) a requirement that the managed care organization |
|
provide ready access to a person who assists recipients in |
|
resolving issues relating to enrollment, plan administration, |
|
education and training, access to services, and grievance |
|
procedures; |
|
(4) a requirement that the managed care organization |
|
provide ready access to a person who assists providers in resolving |
|
issues relating to payment, plan administration, education and |
|
training, and grievance procedures; |
|
(5) a requirement that the managed care organization |
|
provide information and referral about the availability of |
|
educational, social, and other community services that could |
|
benefit a recipient; |
|
(6) procedures for recipient outreach and education; |
|
(7) a requirement that the managed care organization |
|
make payment to a physician or provider for health care services |
|
rendered to a recipient under a managed care plan not later than the |
|
45th day after the date a claim for payment is received with |
|
documentation reasonably necessary for the managed care |
|
organization to process the claim, or within a period, not to exceed |
|
60 days, specified by a written agreement between the physician or |
|
provider and the managed care organization; |
|
(8) a requirement that the commission, on the date of a |
|
recipient's enrollment in a managed care plan issued by the managed |
|
care organization, inform the organization of the recipient's |
|
Medicaid certification date; |
|
(9) a requirement that the managed care organization |
|
comply with Section 533.006 as a condition of contract retention |
|
and renewal; |
|
(10) a requirement that the managed care organization |
|
provide the information required by Section 533.012 and otherwise |
|
comply and cooperate with the [commission's] office of state |
|
inspector general; |
|
(11) a requirement that the managed care |
|
organization's usages of out-of-network providers or groups of |
|
out-of-network providers may not exceed limits for those usages |
|
relating to total inpatient admissions, total outpatient services, |
|
and emergency room admissions determined by the commission; |
|
(12) if the commission finds that a managed care |
|
organization has violated Subdivision (11), a requirement that the |
|
managed care organization reimburse an out-of-network provider for |
|
health care services at a rate that is equal to the allowable rate |
|
for those services, as determined under Sections 32.028 and |
|
32.0281, Human Resources Code; |
|
(13) a requirement that the organization use advanced |
|
practice nurses in addition to physicians as primary care providers |
|
to increase the availability of primary care providers in the |
|
organization's provider network; |
|
(14) a requirement that the managed care organization |
|
reimburse a federally qualified health center or rural health |
|
clinic for health care services provided to a recipient outside of |
|
regular business hours, including on a weekend day or holiday, at a |
|
rate that is equal to the allowable rate for those services as |
|
determined under Section 32.028, Human Resources Code, if the |
|
recipient does not have a referral from the recipient's primary |
|
care physician; and |
|
(15) a requirement that the managed care organization |
|
develop, implement, and maintain a system for tracking and |
|
resolving all provider appeals related to claims payment, including |
|
a process that will require: |
|
(A) a tracking mechanism to document the status |
|
and final disposition of each provider's claims payment appeal; |
|
(B) the contracting with physicians who are not |
|
network providers and who are of the same or related specialty as |
|
the appealing physician to resolve claims disputes related to |
|
denial on the basis of medical necessity that remain unresolved |
|
subsequent to a provider appeal; and |
|
(C) the determination of the physician resolving |
|
the dispute to be binding on the managed care organization and |
|
provider. |
|
SECTION 17. Subsections (a), (b), (c), and (e), Section |
|
533.012, Government Code, are amended to read as follows: |
|
(a) Each managed care organization contracting with the |
|
commission under this chapter shall submit to the office of state |
|
inspector general [commission]: |
|
(1) a description of any financial or other business |
|
relationship between the organization and any subcontractor |
|
providing health care services under the contract; |
|
(2) a copy of each type of contract between the |
|
organization and a subcontractor relating to the delivery of or |
|
payment for health care services; |
|
(3) a description of the fraud control program used by |
|
any subcontractor that delivers health care services; and |
|
(4) a description and breakdown of all funds paid to |
|
the managed care organization, including a health maintenance |
|
organization, primary care case management, and an exclusive |
|
provider organization, necessary for the office [commission] to |
|
determine the actual cost of administering the managed care plan. |
|
(b) The information submitted under this section must be |
|
submitted in the form required by the office of state inspector |
|
general [commission] and be updated as required by the office |
|
[commission]. |
|
(c) The office [commission's office] of state inspector |
|
general [investigations and enforcement] shall review the |
|
information submitted under this section as appropriate in the |
|
investigation of fraud in the Medicaid managed care program. The |
|
comptroller may review the information in connection with the |
|
health care fraud study conducted by the comptroller. |
|
(e) Information submitted to the office of state inspector |
|
general [commission] under Subsection (a)(1) is confidential and |
|
not subject to disclosure under Chapter 552[, Government Code]. |
|
SECTION 18. Subsection (b), Section 2054.376, Government |
|
Code, is amended to read as follows: |
|
(b) This subchapter does not apply to: |
|
(1) the Department of Public Safety's use for criminal |
|
justice or homeland security purposes of a federal database or |
|
network; |
|
(2) a Texas equivalent of a database or network |
|
described by Subdivision (1) that is managed by the Department of |
|
Public Safety; |
|
(3) the uniform statewide accounting system, as that |
|
term is used in Subchapter C, Chapter 2101; |
|
(4) the state treasury cash and treasury management |
|
system; [or] |
|
(5) a database or network managed by the comptroller |
|
to: |
|
(A) collect and process multiple types of taxes |
|
imposed by the state; or |
|
(B) manage or administer fiscal, financial, |
|
revenue, and expenditure activities of the state under Chapter 403 |
|
and Chapter 404; or |
|
(6) the office of state inspector general's use, for |
|
criminal justice and statutorily mandated confidentiality |
|
purposes, of a federal or state database or network. |
|
SECTION 19. Subsection (b), Section 21.014, Human Resources |
|
Code, is amended to read as follows: |
|
(b) The [person employed by the department as] inspector |
|
general shall make reports to and consult with the chairman of the |
|
board regarding: |
|
(1) the selection of internal audit topics; |
|
(2) the establishment of internal audit priorities; |
|
and |
|
(3) the findings of each regular or special internal |
|
audit initiative. |
|
SECTION 20. Section 32.003, Human Resources Code, is |
|
amended by adding Subdivision (5) to read as follows: |
|
(5) "Office of state inspector general" means the |
|
office of state inspector general established under Chapter 422, |
|
Government Code. |
|
SECTION 21. Section 32.0291, Human Resources Code, is |
|
amended to read as follows: |
|
Sec. 32.0291. PREPAYMENT REVIEWS AND POST PAYMENT HOLDS. |
|
(a) Notwithstanding any other law, the office of state inspector |
|
general [department] may: |
|
(1) perform a prepayment review of a claim for |
|
reimbursement under the medical assistance program to determine |
|
whether the claim involves fraud, waste, or abuse; and |
|
(2) as necessary to perform that review, withhold |
|
payment of the claim for not more than five working days without |
|
notice to the person submitting the claim. |
|
(b) Notwithstanding any other law, the office of state |
|
inspector general [department] may impose a postpayment hold on |
|
payment of future claims submitted by a provider if the office |
|
[department] has reliable evidence that the provider has committed |
|
fraud, waste, abuse, or wilful misrepresentation regarding a claim |
|
for reimbursement under the medical assistance program. The office |
|
[department] must notify the provider of the postpayment hold not |
|
later than the fifth working day after the date the hold is imposed. |
|
(c) On timely written request by a provider subject to a |
|
postpayment hold under Subsection (b), the office of state |
|
inspector general [department] shall file a request with the State |
|
Office of Administrative Hearings for an expedited administrative |
|
hearing regarding the hold. The provider must request an expedited |
|
hearing under this subsection not later than the 10th day after the |
|
date the provider receives notice from the office [department] |
|
under Subsection (b). The office [department] shall discontinue |
|
the hold unless the office [department] makes a prima facie showing |
|
at the hearing that the evidence relied on by the office |
|
[department] in imposing the hold is relevant, credible, and |
|
material to the issue of fraud, waste, abuse, or wilful |
|
misrepresentation. |
|
(d) The state inspector general [department] shall adopt |
|
rules that allow a provider subject to a postpayment hold under |
|
Subsection (b) to seek an informal resolution of the issues |
|
identified by the office [department] in the notice provided under |
|
that subsection. A provider must seek an informal resolution under |
|
this subsection not later than the deadline prescribed by |
|
Subsection (c). A provider's decision to seek an informal |
|
resolution under this subsection does not extend the time by which |
|
the provider must request an expedited administrative hearing under |
|
Subsection (c). However, a hearing initiated under Subsection (c) |
|
shall be stayed at the office's [department's] request until the |
|
informal resolution process is completed. |
|
SECTION 22. Section 32.032, Human Resources Code, is |
|
amended to read as follows: |
|
Sec. 32.032. PREVENTION AND DETECTION OF FRAUD AND ABUSE. |
|
The state inspector general [department] shall adopt reasonable |
|
rules for minimizing the opportunity for fraud and abuse, for |
|
establishing and maintaining methods for detecting and identifying |
|
situations in which a question of fraud or abuse in the program may |
|
exist, and for referring cases where fraud or abuse appears to exist |
|
to the appropriate law enforcement agencies for prosecution. |
|
SECTION 23. Subsections (a) through (d), Section 32.0321, |
|
Human Resources Code, are amended to read as follows: |
|
(a) The office of state inspector general [department] by |
|
rule may require each provider of medical assistance in a provider |
|
type that has demonstrated significant potential for fraud or abuse |
|
to file with the office [department] a surety bond in a reasonable |
|
amount. The office [department] by rule shall require a provider of |
|
medical assistance to file with the office [department] a surety |
|
bond in a reasonable amount if the office [department] identifies a |
|
pattern of suspected fraud or abuse involving criminal conduct |
|
relating to the provider's services under the medical assistance |
|
program that indicates the need for protection against potential |
|
future acts of fraud or abuse. |
|
(b) The bond under Subsection (a) must be payable to the |
|
office of state inspector general [department] to compensate the |
|
office [department] for damages resulting from or penalties or |
|
fines imposed in connection with an act of fraud or abuse committed |
|
by the provider under the medical assistance program. |
|
(c) Subject to Subsection (d) or (e), the office of state |
|
inspector general [department] by rule may require each provider of |
|
medical assistance that establishes a resident's trust fund account |
|
to post a surety bond to secure the account. The bond must be |
|
payable to the office [department] to compensate residents of the |
|
bonded provider for trust funds that are lost, stolen, or otherwise |
|
unaccounted for if the provider does not repay any deficiency in a |
|
resident's trust fund account to the person legally entitled to |
|
receive the funds. |
|
(d) The office of state inspector general [department] may |
|
not require the amount of a surety bond posted for a single facility |
|
provider under Subsection (c) to exceed the average of the total |
|
average monthly balance of all the provider's resident trust fund |
|
accounts for the 12-month period preceding the bond issuance or |
|
renewal date. |
|
SECTION 24. Section 32.0322, Human Resources Code, is |
|
amended to read as follows: |
|
Sec. 32.0322. CRIMINAL HISTORY RECORD INFORMATION. |
|
(a) The office of state inspector general and the department may |
|
obtain from any law enforcement or criminal justice agency the |
|
criminal history record information that relates to a provider |
|
under the medical assistance program or a person applying to enroll |
|
as a provider under the medical assistance program. |
|
(b) The office of state inspector general [department] by |
|
rule shall establish criteria for revoking a provider's enrollment |
|
or denying a person's application to enroll as a provider under the |
|
medical assistance program based on the results of a criminal |
|
history check. |
|
SECTION 25. Subsection (d), Section 32.070, Human Resources |
|
Code, is amended to read as follows: |
|
(d) This section does not apply to a computerized audit |
|
conducted using the Medicaid Fraud Detection Audit System or an |
|
audit or investigation of fraud and abuse conducted by the Medicaid |
|
fraud control unit of the office of the attorney general, the office |
|
of the state auditor, the office of state [the] inspector general, |
|
or the Office of Inspector General in the United States Department |
|
of Health and Human Services. |
|
SECTION 26. Subsection (e), Section 33.015, Human Resources |
|
Code, is amended to read as follows: |
|
(e) The department shall require a person exempted under |
|
this section from making a personal appearance at department |
|
offices to provide verification of the person's entitlement to the |
|
exemption on initial eligibility certification and on each |
|
subsequent periodic eligibility recertification. If the person |
|
does not provide verification and the department considers the |
|
verification necessary to protect the integrity of the food stamp |
|
program, the department shall initiate a fraud referral to the |
|
[department's] office of state inspector general. |
|
SECTION 27. Section 20.038, Business & Commerce Code, is |
|
amended to read as follows: |
|
Sec. 20.038. EXEMPTION FROM SECURITY FREEZE. A security |
|
freeze does not apply to a consumer report provided to: |
|
(1) a state or local governmental entity, including a |
|
law enforcement agency or court or private collection agency, if |
|
the entity, agency, or court is acting under a court order, warrant, |
|
subpoena, or administrative subpoena; |
|
(2) a child support agency as defined by Section |
|
101.004, Family Code, acting to investigate or collect child |
|
support payments or acting under Title IV-D of the Social Security |
|
Act (42 U.S.C. Section 651 et seq.); |
|
(3) the office of state inspector general [Health and
|
|
Human Services Commission] acting to investigate fraud, waste, or |
|
abuse in state agencies under Chapter 422, Government Code, or |
|
other law [under Section 531.102, Government Code]; |
|
(4) the comptroller acting to investigate or collect |
|
delinquent sales or franchise taxes; |
|
(5) a tax assessor-collector acting to investigate or |
|
collect delinquent ad valorem taxes; |
|
(6) a person for the purposes of prescreening as |
|
provided by the Fair Credit Reporting Act (15 U.S.C. Section 1681 et |
|
seq.), as amended; |
|
(7) a person with whom the consumer has an account or |
|
contract or to whom the consumer has issued a negotiable |
|
instrument, or the person's subsidiary, affiliate, agent, |
|
assignee, prospective assignee, or private collection agency, for |
|
purposes related to that account, contract, or instrument; |
|
(8) a subsidiary, affiliate, agent, assignee, or |
|
prospective assignee of a person to whom access has been granted |
|
under Section 20.037(b); |
|
(9) a person who administers a credit file monitoring |
|
subscription service to which the consumer has subscribed; |
|
(10) a person for the purpose of providing a consumer |
|
with a copy of the consumer's report on the consumer's request; |
|
(11) a check service or fraud prevention service |
|
company that issues consumer reports: |
|
(A) to prevent or investigate fraud; or |
|
(B) for purposes of approving or processing |
|
negotiable instruments, electronic funds transfers, or similar |
|
methods of payment; |
|
(12) a deposit account information service company |
|
that issues consumer reports related to account closures caused by |
|
fraud, substantial overdrafts, automated teller machine abuses, or |
|
similar negative information regarding a consumer to an inquiring |
|
financial institution for use by the financial institution only in |
|
reviewing a consumer request for a deposit account with that |
|
institution; or |
|
(13) a consumer reporting agency that: |
|
(A) acts only to resell credit information by |
|
assembling and merging information contained in a database of |
|
another consumer reporting agency or multiple consumer reporting |
|
agencies; and |
|
(B) does not maintain a permanent database of |
|
credit information from which new consumer reports are produced. |
|
SECTION 28. Article 2.12, Code of Criminal Procedure, is |
|
amended to read as follows: |
|
Art. 2.12. WHO ARE PEACE OFFICERS. The following are peace |
|
officers: |
|
(1) sheriffs, their deputies, and those reserve |
|
deputies who hold a permanent peace officer license issued under |
|
Chapter 1701, Occupations Code; |
|
(2) constables, deputy constables, and those reserve |
|
deputy constables who hold a permanent peace officer license issued |
|
under Chapter 1701, Occupations Code; |
|
(3) marshals or police officers of an incorporated |
|
city, town, or village, and those reserve municipal police officers |
|
who hold a permanent peace officer license issued under Chapter |
|
1701, Occupations Code; |
|
(4) rangers and officers commissioned by the Public |
|
Safety Commission and the Director of the Department of Public |
|
Safety; |
|
(5) investigators of the district attorneys', criminal |
|
district attorneys', and county attorneys' offices; |
|
(6) law enforcement agents of the Texas Alcoholic |
|
Beverage Commission; |
|
(7) each member of an arson investigating unit |
|
commissioned by a city, a county, or the state; |
|
(8) officers commissioned under Section 37.081, |
|
Education Code, or Subchapter E, Chapter 51, Education Code; |
|
(9) officers commissioned by the General Services |
|
Commission; |
|
(10) law enforcement officers commissioned by the |
|
Parks and Wildlife Commission; |
|
(11) airport police officers commissioned by a city |
|
with a population of more than 1.18 million that operates an airport |
|
that serves commercial air carriers; |
|
(12) airport security personnel commissioned as peace |
|
officers by the governing body of any political subdivision of this |
|
state, other than a city described by Subdivision (11), that |
|
operates an airport that serves commercial air carriers; |
|
(13) municipal park and recreational patrolmen and |
|
security officers; |
|
(14) security officers and investigators commissioned |
|
as peace officers by the comptroller; |
|
(15) officers commissioned by a water control and |
|
improvement district under Section 49.216, Water Code; |
|
(16) officers commissioned by a board of trustees |
|
under Chapter 54, Transportation Code; |
|
(17) investigators commissioned by the Texas Medical |
|
[State] Board [of Medical Examiners]; |
|
(18) officers commissioned by the board of managers of |
|
the Dallas County Hospital District, the Tarrant County Hospital |
|
District, or the Bexar County Hospital District under Section |
|
281.057, Health and Safety Code; |
|
(19) county park rangers commissioned under |
|
Subchapter E, Chapter 351, Local Government Code; |
|
(20) investigators employed by the Texas Racing |
|
Commission; |
|
(21) officers commissioned under Chapter 554, |
|
Occupations Code; |
|
(22) officers commissioned by the governing body of a |
|
metropolitan rapid transit authority under Section 451.108, |
|
Transportation Code, or by a regional transportation authority |
|
under Section 452.110, Transportation Code; |
|
(23) investigators commissioned by the attorney |
|
general under Section 402.009, Government Code; |
|
(24) security officers and investigators commissioned |
|
as peace officers under Chapter 466, Government Code; |
|
(25) an officer employed by the [Texas] Department of |
|
State Health Services under Section 431.2471, Health and Safety |
|
Code; |
|
(26) officers appointed by an appellate court under |
|
Subchapter F, Chapter 53, Government Code; |
|
(27) officers commissioned by the state fire marshal |
|
under Chapter 417, Government Code; |
|
(28) an investigator commissioned by the commissioner |
|
of insurance under Section 701.104 [Article 1.10D], Insurance Code; |
|
(29) apprehension specialists commissioned by the |
|
Texas Youth Commission as officers under Section 61.0931, Human |
|
Resources Code; |
|
(30) officers appointed by the executive director of |
|
the Texas Department of Criminal Justice under Section 493.019, |
|
Government Code; |
|
(31) investigators commissioned by the Commission on |
|
Law Enforcement Officer Standards and Education under Section |
|
1701.160, Occupations Code; |
|
(32) commission investigators commissioned by the |
|
Texas [Commission on] Private Security Board under Section |
|
1702.061(f), Occupations Code; |
|
(33) the fire marshal and any officers, inspectors, or |
|
investigators commissioned by an emergency services district under |
|
Chapter 775, Health and Safety Code; [and] |
|
(34) officers commissioned by the State Board of |
|
Dental Examiners under Section 254.013, Occupations Code, subject |
|
to the limitations imposed by that section; and |
|
(35) officers commissioned by the office of state |
|
inspector general established under Chapter 422, Government Code. |
|
SECTION 29. The following sections of the Government Code |
|
are repealed: |
|
(1) Section 531.102; |
|
(2) Section 531.1021; |
|
(3) Section 531.103; and |
|
(4) Section 531.104. |
|
SECTION 30. (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 |
|
before the effective date of this Act. A complaint, investigation, |
|
or other proceeding initiated under that section is continued in |
|
accordance with the changes in law made by this Act. |
|
(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 |
|
under that section before the effective date of this Act is governed |
|
by the law that existed when the subpoena was issued, and the former |
|
law is continued in effect for that purpose. |
|
SECTION 31. (a) The office of state inspector general |
|
under Chapter 422, Government Code, as added by this Act, is created |
|
on the effective date of this Act. |
|
(b) On January 1, 2008, the office of inspector general of |
|
the Health and Human Services Commission created under Section |
|
531.102, Government Code, as that section existed before amendment |
|
by this Act, is abolished. |
|
(c) Not later than January 1, 2008: |
|
(1) all powers, duties, obligations, rights, |
|
contracts, records, personal property, unspent appropriations, |
|
state and federal funds, including overhead costs, support costs, |
|
and lease or colocation costs, of the office of inspector general of |
|
the Health and Human Services Commission shall be transferred, as |
|
consistent with this Act, to the office of state inspector general; |
|
(2) all personnel, vacant full-time equivalent |
|
positions, and assets assigned, as of the effective date of this |
|
Act, to the office of inspector general of the Health and Human |
|
Services Commission or engaged in the performance of the functions |
|
of that office shall be transferred, as consistent with this Act, to |
|
the office of state inspector general; |
|
(3) each state agency for which a state agency |
|
inspector general is designated by the state inspector general on |
|
or before October 1, 2007, shall transfer to the office of state |
|
inspector general, as consistent with this Act, all personnel, |
|
vacant full-time equivalent positions, and assets engaged in the |
|
performance of or the support of agency functions relating to the |
|
detection, investigation, and prevention of fraud, waste, and abuse |
|
in the implementation or administration of state or federally |
|
funded programs; |
|
(4) all state and federal funding, including funding |
|
for overhead costs, support costs, and lease or colocation lease |
|
costs, for the functions to be transferred to the office of state |
|
inspector general shall be reallocated to that office; and |
|
(5) for purposes of federal single state agency |
|
funding requirements, any federal funds that may not be |
|
appropriated directly to the office of state inspector general |
|
shall be transferred from the single state agency receiving the |
|
funds to the office of state inspector general if the funds are |
|
intended for a function performed by that office. |
|
(d) All future federal funding to be allocated to the office |
|
of inspector general of the Health and Human Services Commission, |
|
including drawing funds and transferring funds, shall be |
|
renegotiated by the state inspector general for reallocation to the |
|
office of state inspector general. |
|
(e) A state agency for which a state agency inspector |
|
general is designated by the state inspector general after October |
|
1, 2007, shall, not later than the 90th day after the date of the |
|
designation, transfer to the office of state inspector general, as |
|
consistent with this Act, all personnel, vacant full-time |
|
equivalent positions, and assets engaged in the performance of or |
|
the support of agency functions relating to the detection, |
|
investigation, and prevention of fraud, waste, and abuse in the |
|
implementation or administration of state or federally funded |
|
programs. |
|
SECTION 32. (a) The Health and Human Services Commission |
|
shall take all action necessary to provide for the orderly transfer |
|
of the assets and responsibilities of the commission's office of |
|
inspector general to the office of state inspector general. In the |
|
event a transfer is not completed by the date required under this |
|
Act, all possible efforts shall be made to promptly conclude the |
|
transfer. |
|
(b) A rule or form adopted by the office of inspector |
|
general of the Health and Human Services Commission is a rule or |
|
form of the office of state inspector general and remains in effect |
|
until changed by the state inspector general. |
|
(c) A reference in law or administrative rule to the office |
|
of inspector general of the Health and Human Services Commission |
|
means the office of state inspector general. |
|
SECTION 33. (a) This section does not prohibit a person |
|
serving as inspector general of the Health and Human Services |
|
Commission under Subsection (a-1), Section 531.102, Government |
|
Code, immediately before the effective date of this Act, from being |
|
appointed under Chapter 422, Government Code, as added by this Act, |
|
if the person has the qualifications required under that chapter. |
|
(b) As soon as possible after the earlier of the expiration |
|
date of the term of the inspector general of the Health and Human |
|
Services Commission under Section 531.102, Government Code, or the |
|
date the position of inspector general under that law otherwise |
|
becomes vacant, the governor shall appoint the state inspector |
|
general under Chapter 422, Government Code, as added by this Act, to |
|
an initial term expiring February 1, 2009. |
|
SECTION 34. The abolition by this Act of the office of |
|
inspector general of the Health and Human Services Commission under |
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Section 531.102, Government Code, as that section existed before |
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repeal by this Act, does not affect the validity of an action taken |
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by that office before it is abolished. |
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SECTION 35. If, before implementing any provision of this |
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Act, a state agency or the state inspector general appointed under |
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Chapter 422, Government Code, as added by this Act, determines that |
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a waiver or authorization from a federal agency is necessary for |
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implementation of that provision, the agency affected by the |
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provision or the state inspector general shall request the waiver |
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or authorization and may delay implementing that provision until |
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the waiver or authorization is granted. |
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SECTION 36. This Act takes effect immediately if it |
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receives a vote of two-thirds of all the members elected to each |
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house, as provided by Section 39, Article III, Texas Constitution. |
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If this Act does not receive the vote necessary for immediate |
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effect, this Act takes effect September 1, 2007. |
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