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A BILL TO BE ENTITLED
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AN ACT
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relating to the office of inspector general for the Health and Human |
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Services Commission. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 531, Government Code, is amended by |
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adding Subchapter R to read as follows: |
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SUBCHAPTER R. INSPECTOR GENERAL |
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Sec. 531.701. DEFINITIONS. In this subchapter: |
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(1) "Fraud" has the meaning assigned by Section |
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531.1011. |
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(2) "Inspector general" means the inspector general |
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appointed under this subchapter. |
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(3) "Office" means the Office of Inspector General. |
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(4) "Provider" has the meaning assigned by Section |
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531.1011. |
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(5) "Review" includes an inspection, investigation, |
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audit, or similar activity. |
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(6) "State funds" or "state money" includes federal |
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funds or money received and appropriated by the state or for which |
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the state has oversight responsibility. |
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Sec. 531.702. REFERENCE IN OTHER LAW. Notwithstanding any |
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other provision of law, a reference in law or rule to the |
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commission's office of inspector general or the commission's office |
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of investigations and enforcement means the Office of Inspector |
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General. |
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Sec. 531.703. OFFICE OF INSPECTOR GENERAL; ADMINISTRATIVE |
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ATTACHMENT. (a) The office of inspector general is responsible |
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for: |
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(1) the investigation of fraud, waste, and abuse in |
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the provision or funding of health or human services by this state; |
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(2) the enforcement of state law relating to the |
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provision of those services to protect the public; and |
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(3) the investigation, prevention and detection of |
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crime relating to the provision of those services. |
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(b) The office is part of the single state Medicaid agency |
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and is administratively attached to the commission. The commission |
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shall provide to the office administrative support services from |
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the commission and from health and human services agencies. |
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Sec. 531.704. SERVICE LEVEL AGREEMENT; FUNDS. (a) The |
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commission and the office shall enter into a service level |
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agreement that establishes the performance standards and |
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deliverables with regard to administrative support by the |
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commission. |
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(b) The service level agreement must be reviewed at least |
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annually to ensure that services and deliverables are provided in |
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accordance with the agreement. |
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(c) The commission shall request, apply for, and receive for |
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the office any appropriations or other money from this state or the |
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federal government, and shall disburse all such funds to the office |
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as appropriated. |
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(d) The commission shall provide to the office for the state |
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fiscal biennium beginning September 1, 2009, the same level of |
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administrative support the commission provided to the office |
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established under former Section 531.102 for the state fiscal |
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biennium beginning September 1, 2007. This subsection expires |
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January 1, 2012. |
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Sec. 531.705. DUTIES OF COMMISSION. (a) The commission |
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shall: |
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(1) provide administrative assistance to the office; |
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and |
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(2) coordinate administrative responsibilities with |
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the office to avoid unnecessary duplication of duties. |
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(b) The commission may not take an action that affects or |
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relates to the validity, status, or terms of an interagency |
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agreement or a contract to which the office is a party without the |
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office's approval. |
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Sec. 531.706. INDEPENDENCE OF OFFICE. (a) Except as |
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otherwise provided by this chapter, the office and inspector |
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general operate independently of the commission. |
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(b) The inspector general, not the executive commissioner, |
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supervises the office staff and manages the operations of the |
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office. |
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(c) The inspector general shall have operational authority |
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over and responsibility for the: |
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(1) management of the daily operations of the office, |
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including the organization and management of the office and office |
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operating procedures; |
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(2) allocation of resources within the office; |
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(3) personnel and employment policies; |
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(4) contracting, purchasing, and related policies, |
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subject to other laws relating to state agency contracting and |
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purchasing; |
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(5) information resources systems used by the office; |
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(6) location of office facilities; |
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(7) coordination of office activities with activities |
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of other state agencies, including other health and human services |
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agencies. |
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Sec. 531.707. INSPECTOR GENERAL; APPOINTMENT AND TERM. (a) |
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The governor shall appoint an inspector general to serve as |
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director of the office. |
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(b) The inspector general reports to the governor and serves |
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a two-year term that expires on February 1 of each odd-numbered |
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year. |
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(c) The inspector general is a state officer. |
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Section 531.708. CONFLICT OF INTEREST. (a) The inspector |
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general may not serve as an ex officio member on the governing body |
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of a governmental entity. |
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(b) The inspector general may not have a financial interest |
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in the transactions of the office, a health and human services |
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agency, or a health or human services provider. |
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Section 531.709. RULEMAKING BY INSPECTOR GENERAL. (a) |
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Notwithstanding Section 531.0055 (e) and any other law, the |
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inspector general shall adopt the rules necessary to administer the |
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functions of the office, including rules to address the imposition |
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of sanctions and penalties for violations and due process |
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requirements for imposing sanctions and penalties, as well as rules |
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relating to the eligibility of providers and contractors to |
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participate in health and human services programs. |
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(b) A rule, standard, or form adopted by the executive |
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commissioner, the commission, or a health and human services agency |
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that is necessary to accomplish the duties of the office is |
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considered to also be a rule, standard, or form of the office and |
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remains in effect as a rule, standard, or form of the office until |
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changed by the inspector general. |
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(c) The office may submit proposed rules and adopted rules |
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to the commission for publication. The executive commissioner or |
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commission may not amend or modify a rule submitted by the office. |
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(d) The rules must include standards for the office that |
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emphasize: |
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(1) coordinating investigative efforts to |
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aggressively recover money; |
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(2) allocating resources to cases that have the |
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strongest supportive evidence and the greatest potential for |
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recovery of money; and |
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(3) maximizing opportunities for referral of cases to |
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the office of the attorney general. |
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Sec. 531.710. EMPLOYEES; MEDICAL REVIEW OFFICER; TRAINING. |
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(a) The inspector general may employ personnel as necessary |
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to implement the duties of the office. |
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(b) The inspector general shall employ a physician as the |
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medical review officer to perform reviews and provide information |
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and consultation as appropriate when the matter at issue involves |
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or requires medical expertise. |
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(c) The inspector general shall train office personnel to |
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pursue priority Medicaid and other health and human services fraud, |
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waste, and abuse cases efficiently and as necessary. |
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(d) The inspector general may contract with certified |
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public accountants, management consultants, or other professional |
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experts necessary to enable the inspector general and office |
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personnel to independently perform the functions of the inspector |
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general's office. |
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(e) The inspector general may require employees of health |
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and human services agencies to provide assistance to the office in |
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connection with the office's duties relating to the investigation |
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of fraud, waste, and abuse in the provision of health and human |
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services. |
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Sec. 531.711. REVIEW AUTHORITY. (a) The inspector general |
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may review any activity or operation of a health and human services |
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agency, health or human services provider, or person in this state |
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that is related to the investigation, detection, or prevention of |
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fraud, waste, or abuse, or official or employee misconduct, in a |
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state or state-funded health or human services program. A review |
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may include an inspection, investigation, audit, or other similar |
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activity inquiring into a specific act or allegation of, or a |
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specific financial transaction or practice that may involve, |
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impropriety, malfeasance, or nonfeasance in the obligation, |
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spending, receipt, or other use of state money. |
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(b) The executive commissioner, the commission, or a health |
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and human services agency of this state may not impair, prohibit, or |
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attempt to influence the inspector general in initiating, |
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conducting, or completing a review. |
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(c) The inspector general may conduct reviews, including |
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financial or performance audits regarding the use and effectiveness |
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of state funds, including contract and grant funds, administered by |
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a person or state agency receiving the funds in connection with a |
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state or state-funded health or human services program. |
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Sec. 531.712. INITIATION OF REVIEW. The inspector general |
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may initiate a review: |
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(1) on the inspector general's own initiative; |
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(2) at the request of the commission or executive |
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commissioner; or |
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(3) based on a complaint from any source concerning a |
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matter described by Section 531.711. |
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Sec. 531.713. INTEGRITY REVIEW. (a) The office shall |
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conduct an integrity review to determine whether there is |
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sufficient basis to warrant a full investigation on receipt of any |
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complaint of fraud, waste, or abuse of funds in the state Medicaid |
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program from any source. |
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(b) An integrity review must begin not later than the 30th |
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day after the date the office receives a complaint or has reason to |
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believe that Medicaid fraud, waste, or abuse has occurred. An |
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integrity review shall be completed not later than the 90th day |
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after the date the review began. |
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(c) If the findings of an integrity review give the office |
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reason to believe that an incident of fraud involving possible |
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criminal conduct has occurred in the state Medicaid program, the |
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office must take the following action, as appropriate, not later |
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than the 30th day after the completion of the integrity review: |
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(1) if a provider is suspected of fraud involving |
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criminal conduct, the office must refer the case to the state's |
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Medicaid fraud control unit, provided that the criminal referral |
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does not preclude the office from continuing its investigation of |
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the provider or preclude the imposition of appropriate |
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administrative or civil sanctions; or |
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(2) if there is reason to believe that a recipient of |
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funds has defrauded the Medicaid program, the office may conduct a |
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full investigation of the suspected fraud. |
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Sec. 531.714. ACCESS TO INFORMATION. (a) To further a |
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review conducted by the office, the inspector general is entitled |
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to full and unrestricted access to all offices, limited-access or |
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restricted areas, employees, books, papers, records, documents, |
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equipment, computers, databases, systems, accounts, reports, |
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vouchers, or other information, including confidential |
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information, electronic data, and internal records relevant to the |
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functions of the office, maintained by a person, health and human |
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services agency, or health or human services provider in connection |
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with a state or state-funded health or human services program. |
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(b) The inspector general may not access data or other |
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information the release of which is restricted under federal law |
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unless the office is in compliance with all applicable federal |
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regulations governing such access. |
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Sec. 531.715. COOPERATION REQUIRED. To further a review |
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conducted by the inspector general's office, the inspector general |
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may require medical or other professional assistance from the |
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executive commissioner, the commission, a health and human services |
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agency, or an auditor, accountant, or other employee of the |
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commission or agency. |
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Sec. 531.716. REFERRAL TO STATE MEDICAID FRAUD CONTROL |
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UNIT. (a) At the time the office learns or has reason to suspect |
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that a health or human services provider 's records related to |
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participation in the state Medicaid program are being withheld, |
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concealed, destroyed, fabricated, or in any way falsified, the |
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office shall immediately refer the case to the state's Medicaid |
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fraud control unit. |
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(b) A criminal referral under Subsection (a) does not |
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preclude the office from continuing its investigation of a health |
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or human services provider or the imposition of appropriate |
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administrative or civil sanctions. |
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Sec. 531.717. HOLD ON CLAIM REIMBURSEMENT PAYMENT; |
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EXCLUSION FROM PROGRAMS. (a) In addition to other instances |
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authorized under state or federal law, the office shall impose |
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without prior notice a hold on payment of claims for reimbursement |
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submitted by a health or human services provider to compel |
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production of records related to participation in the state |
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Medicaid program or on request of the state's Medicaid fraud |
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control unit, as applicable. |
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(b) The office must notify the health or human services |
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provider of the hold on payment not later than the fifth working day |
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after the date the payment hold is imposed. |
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(c) The office shall, in consultation with the state 's |
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Medicaid fraud control unit, establish guidelines under which holds |
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on payment or exclusions from a state or state-funded program: |
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(1) may permissively be imposed on a health or human |
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services provider; or |
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(2) shall automatically be imposed on a provider. |
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(d) A health or human services provider subject to a hold on |
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payment or excluded from a program under this section is entitled to |
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a hearing on the hold or exclusion. A hearing under this subsection |
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is a contested case hearing under Chapter 2001. The State Office of |
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Administrative Hearings shall conduct the hearing. After the |
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hearing, the office, subject to judicial review, shall make a final |
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determination. The commission, a health and human services agency, |
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and the office of the attorney general are entitled to intervene as |
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parties in the contested case. |
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Sec. 531.718. REQUEST FOR EXPEDITED HEARING. (a) On timely |
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written request by a health or human services provider subject to a |
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hold on payment under Section 531.717, other than a hold requested |
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by the state's Medicaid fraud control unit, the office shall file a |
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request with the State Office of Administrative Hearing for an |
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expedited administrative hearing regarding the hold. |
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(b) The health or human services provider must request an |
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expedited hearing not later than the 10th day after the date the |
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provider receives notice from the office under Section 531.717(b). |
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(c) The office may enter into a memorandum of understanding |
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with the State Office of Administrative Hearings to facilitate the |
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docketing and hearing of contested case hearings. |
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Sec. 531.719. INFORMAL RESOLUTION. (a) The inspector |
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general shall adopt rules that allow a health or human services |
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provider subject to a hold on payment under Section 531.717, other |
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than a hold requested by the state's Medicaid fraud control unit, to |
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seek an informal resolution of the issues identified by the office |
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in the notice provided under that section. |
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(b) A health or human services provider must seek an |
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informal resolution not later than the 10th day after the date the |
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provider receives notice from the office under Section 531.717(b). |
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(c) A health or human services provider's decision to seek |
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an informal resolution does not extend the time by which the |
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provider must request an expedited administrative hearing under |
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Section 531.718. |
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(d) A hearing initiated under Section 531.717 shall be |
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stayed at the office's request until the informal resolution |
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process is completed. |
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Sec. 531.720. EMPLOYEE REPORTS. The inspector general may |
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require employees at the commission or a health and human services |
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agency to report to the office information regarding fraud, waste, |
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misuse or abuse of funds or resources, corruption, or illegal acts. |
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Sec. 531.721. SUBPOENAS. (a) The inspector general may |
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issue a subpoena to compel the attendance of a relevant witness or |
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the production, for inspection or copying, of relevant evidence in |
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connection with a review conducted under this subchapter. |
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(b) A subpoena may be served personally or by certified |
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mail. |
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(c) If a person fails to comply with a subpoena, the |
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inspector general, acting through the attorney general, may file |
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suit to enforce the subpoena in a district court in this state. |
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(d) On finding that good cause exists for issuing the |
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subpoena, the court shall order the person to comply with the |
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subpoena. The court may hold in contempt a person who fails to obey |
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the court order. |
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(e) The reimbursement of the expenses of a witness whose |
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attendance is compelled under this section is governed by Section |
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2001.103. |
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Sec. 531.722. INTERNAL AUDITOR. (a) In this section, |
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"internal auditor" means a person appointed under Section 2102.006. |
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(b) The internal auditor for a health and human services |
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agency shall provide the inspector general with a copy of the |
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agency's internal audit plan to: |
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(1) assist in the coordination of efforts between the |
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inspector general and the internal auditor; and |
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(2) limit duplication of effort regarding reviews by |
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the inspector general and internal auditor. |
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(c) The internal auditor shall provide to the inspector |
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general all final audit reports concerning audits of any: |
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(1) part or division of the agency; |
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(2) contract, procurement, or grant; and |
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(3) program conducted by the agency. |
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Sec. 531.723. COOPERATION WITH LAW ENFORCEMENT OFFICIALS |
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AND OTHER ENTITIES. (a) The inspector general may provide |
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information and evidence relating to criminal acts to the state |
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auditor's office and appropriate law enforcement officials. |
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(b) The inspector general may refer matters for further |
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civil, criminal, and administrative action to appropriate |
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administrative and prosecutorial agencies, including the attorney |
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general. |
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(c) The inspector general may enter into a memorandum of |
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understanding with a law enforcement or prosecutorial agency, |
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including the office of the attorney general, to assist in |
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conducting a review under this subchapter. |
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Sec. 531.724. COOPERATION AND COORDINATION WITH STATE |
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AUDITOR. |
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(a) The state auditor may, on request of the inspector |
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general, provide appropriate information or other assistance to the |
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inspector general or office, as determined by the state auditor. |
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(b) The inspector general may meet with the state auditor 's |
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office to coordinate a review conducted under this subchapter, |
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share information, or schedule work plans. |
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(c) The state auditor is entitled to access all information |
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maintained by the inspector general, including vouchers, |
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electronic data, internal records, and information obtained under |
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Section 531.714 or subject to Section 531.731. |
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(d) Any information obtained or provided by the state |
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auditor under this section is confidential and not subject to |
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disclosure under Chapter 552. |
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Sec. 531.725. PREVENTION. (a) The inspector general may |
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recommend to the commission and executive commissioner policies on: |
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(1) promoting economical and efficient administration |
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of state funds administered by an individual or entity that |
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received the funds from a health and human services agency; and |
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(2) preventing and detecting fraud, waste, and abuse |
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in the administration of those funds. |
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(b) The inspector general may provide training or other |
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education regarding the prevention of fraud, waste, or abuse to |
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employees of a health and human services agency. The training or |
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education provided must be approved by the presiding officer of the |
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agency. |
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Sec. 531.726. RULEMAKING BY EXECUTIVE COMMISSIONER. The |
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executive commissioner may adopt rules governing a health and human |
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services agency's response to reports and referrals from the |
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inspector general on issues identified by the inspector general |
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related to the agency or a contractor of the agency. |
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Sec. 531.727. ALLEGATIONS OF MISCONDUCT AGAINST PRESIDING |
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OFFICER. If a review by the inspector general involves allegations |
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that a presiding officer of a health and human services agency has |
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engaged in misconduct, the inspector general shall report to the |
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governor during the review until the report is completed or the |
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review is closed without a finding. |
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Sec. 531.728. PERIODIC REPORTING TO STATE AUDITOR AND |
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EXECUTIVE COMMISSIONER REQUIRED. The inspector general shall |
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timely inform the state auditor and the executive commissioner of |
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the initiation of a review of a health and human services agency |
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program and the ongoing status of each review. |
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Sec. 531.729. REPORTING OFFICE FINDINGS. The inspector |
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general shall report the findings of any review or investigation |
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conducted by the office to: |
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(1) the executive commissioner; |
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(2) the governor; |
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(3) the lieutenant governor; |
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(4) the speaker of the house of representatives; |
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(5) the state auditor 's office; and |
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(6) appropriate law enforcement and prosecutorial |
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agencies, including the office of the attorney general, if the |
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findings suggest the probability of criminal conduct. |
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Sec. 531.730. FLAGRANT VIOLATIONS; IMMEDIATE REPORT. The |
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inspector general shall immediately report to the executive |
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commissioner, the governor's general counsel, and the state auditor |
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a problem deemed by the inspector general to be particularly |
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serious or flagrant, and relating to the administration of a |
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program, operation of a health and human services agency, or |
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interference with an inspector general review. |
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Sec. 531.731. INFORMATION CONFIDENTIAL. (a) Except as |
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provided by this section, Sections 531.103, 531.729, and 531.733, |
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all information and material compiled or maintained by the |
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inspector general during a review under this subchapter is: |
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(1) confidential and not subject to disclosure under |
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Chapter 552; and |
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(2) not subject to disclosure, discovery, subpoena, or |
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other means of legal compulsion for release to anyone other than the |
|
state auditor's office, the commission, or the office or its agents |
|
involved in the review related to that information or material. |
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(b) Subsection (a) applies to information the inspector |
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general is required to disclose under Sections 531.727, 531.728, |
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531.730, and 531.732. |
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(c) As the inspector general determines appropriate based |
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on evidence sufficient to support an allegation, information |
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relating to a review may be disclosed to: |
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(1) a law enforcement agency; |
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(2) the attorney general's office; |
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(3) the state auditor's office; or |
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(4) the commission.; or |
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(5) a licensing or regulatory agency. |
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(d) A person that receives information under Subsections |
|
(b) and (c) may not disclose the information except to the extent |
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that disclosure is consistent with the authorized purpose for which |
|
the person first obtained the information. |
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Sec. 531.732. DRAFT OF FINAL REPORT; AGENCY RESPONSE. |
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(a) Except in cases in which the office has determined that |
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potential fraud, waste, or abuse exists, or a criminal violation |
|
has occurred, the office shall provide a draft of the final report |
|
of any review of the operations of a health and human services |
|
agency to the presiding officer of the agency before publishing the |
|
office's final report. |
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(b) The health and human services agency may provide a |
|
response to the office's draft report in the manner prescribed by |
|
the office not later than the 10th day after the date the draft |
|
report is received by the agency. The inspector general by rule |
|
shall specify the format and requirements of the agency response. |
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(c) Notwithstanding Subsection (a), the office may not |
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provide a draft report to the presiding officer of the agency if in |
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the inspector general's opinion providing the draft report could |
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negatively affect any anticipated civil or criminal proceedings. |
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(d) The office may include any portion of the agency's |
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response in the office's final report. |
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Sec. 531.733. FINAL REVIEW REPORTS; AGENCY RESPONSE. (a) |
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The inspector general shall prepare a final report for each review |
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conducted under this subchapter. The final report must include: |
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(1) a summary of the activities performed by the |
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inspector general in conducting the review; |
|
(2) a determination of whether wrongdoing was found; |
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and |
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(3) a description of any findings of wrongdoing. |
|
(b) The inspector general's final review reports are |
|
subject to disclosure under Chapter 552. |
|
(c) All working papers and other documents related to |
|
compiling the final review reports remain confidential and are not |
|
subject to disclosure under Chapter 552. |
|
(d) Not later than the 60th day after the date the office |
|
issues a final report that identifies deficiencies or |
|
inefficiencies in, or recommends corrective measures in the |
|
operations of, a health and human services agency, the agency shall |
|
file a 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 |
|
inefficiencies or the office 's recommended corrective measures, as |
|
applicable. |
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Sec. 531.734. STATE AUDITOR AUDITS, INVESTIGATIONS, AND |
|
ACCESS TO INFORMATION NOT IMPAIRED. This subchapter or other law |
|
related to the operation of the inspector general does not prohibit |
|
the state auditor from conducting an audit, investigation, or other |
|
review or from having full and complete access to all records and |
|
other information, including witnesses and electronic data, that |
|
the state auditor considers necessary for the audit, investigation, |
|
or other review. |
|
Sec. 531.735. AUTHORITY OF STATE AUDITOR TO CONDUCT TIMELY |
|
AUDITS NOT IMPAIRED. This chapter or other law related to the |
|
operation of the inspector general does not take precedence over |
|
the authority of the state auditor to conduct an audit under Chapter |
|
321 or other law. |
|
Sec. 531.736. BUDGET. (a) The inspector general shall |
|
submit a budget in accordance with the reporting requirements of |
|
the General Appropriations Act. |
|
(b) The inspector general shall submit to the commission a |
|
legislative appropriations request and an operating budget in |
|
accordance with the service level agreement entered into under |
|
Section 531.704 and applicable law. |
|
(c) The commission shall submit the office's appropriations |
|
request and, if required by or under law, operating budget to the |
|
legislature. The request or budget is not subject to review, |
|
alteration, or modification by the commission or executive |
|
commissioner before submission to the legislature. |
|
Sec. 531.737. COSTS. (a) The inspector general shall |
|
maintain information regarding the cost of reviews. |
|
(b) The inspector general may cooperate with appropriate |
|
administrative and prosecutorial agencies, including the office of |
|
the attorney general, in recovering costs incurred under this |
|
subchapter from nongovernmental entities, including contractors or |
|
individuals involved in: |
|
(1) violations of applicable state or federal rules or |
|
statutes; |
|
(2) abusive or willful misconduct; or |
|
(3) violations of a provider contract or program |
|
policy. |
|
(c) In criminal cases the inspector general and the Office |
|
of Attorney General shall cooperate to ensure that all appropriate |
|
evidence is submitted to the court in all criminal prosecutions |
|
towards ensuring that restitution is ordered, to include the |
|
overpayment and the costs incurred under this subchapter, as a |
|
condition of probation or as a condition of parole. |
|
Sec. 531.738. ADMINISTRATIVE OR CIVIL PENALTY; INJUNCTION. |
|
(a) The office may: |
|
(1) act for a health and human services agency in the |
|
assessment by the office of administrative or civil penalties the |
|
agency is authorized to assess under applicable law; and |
|
(2) request that the attorney general obtain an |
|
injunction to prevent a person from disposing of an asset |
|
identified by the office as potentially subject to recovery by the |
|
office due to the person's fraud, waste, or abuse. |
|
(b) If the office imposes an administrative or civil penalty |
|
under Subsection (a) for a health and human services agency: |
|
(1) the health and human services agency may not |
|
impose an administrative or civil penalty against the same person |
|
for the same violation; and |
|
(2) the office shall impose the penalty under |
|
applicable rules of the office, this subchapter, and applicable |
|
laws and rules governing the imposition of a penalty by the health |
|
and human services agency. |
|
Sec. 531.739. PEACE OFFICER INVESTIGATORS. (a) An |
|
investigator assigned to conduct investigations for the office may |
|
be a commissioned peace officer. The number of commissioned peace |
|
officers assigned to conduct investigations may not exceed 15 |
|
percent of the office's full-time equivalent positions. |
|
(b) A commissioned peace officer or otherwise designated |
|
law enforcement officer employed by the office is not entitled to |
|
supplemental benefits from the law enforcement and custodial |
|
officer supplemental retirement fund unless the officer transfers |
|
from a position, without a break in service, that qualifies for |
|
supplemental retirement benefits from the fund. |
|
SECTION 2. Section 531.001, Government Code, is amended by |
|
adding Subdivision (4-a) to read as follows: |
|
(4-a) "Office of inspector general" means the office of |
|
inspector general established under Subchapter R. |
|
SECTION 3. Section 531.008(c), 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. Sections 531.103(a), (c), and (d), Government |
|
Code, are amended to read as follows: |
|
(a) The [commission, acting through the commission's] |
|
office of inspector general[,] and the office of the attorney |
|
general shall enter into a memorandum of understanding to develop |
|
and implement joint written procedures for processing cases of |
|
suspected fraud, waste, or abuse, as those terms are defined by |
|
state or federal law, or other violations of state or federal law |
|
under the state Medicaid program or other program administered by |
|
the commission or a health and human services agency, including the |
|
financial assistance program under Chapter 31, Human Resources |
|
Code, a nutritional assistance program under Chapter 33, Human |
|
Resources Code, and the child health plan program. The memorandum |
|
of understanding shall require: |
|
(1) the office of inspector general and the office of |
|
the attorney general to set priorities and guidelines for referring |
|
cases to appropriate state agencies for investigation, |
|
prosecution, or other disposition to enhance deterrence of fraud, |
|
waste, 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; |
|
(1-a) the office of inspector general to refer each |
|
case of suspected provider fraud, waste, or abuse to the office of |
|
the attorney general not later than the 20th business day after the |
|
date the office of inspector general determines that the existence |
|
of fraud, waste, or abuse is reasonably indicated; |
|
(1-b) the office of the attorney general to take |
|
appropriate action in response to each case referred to the |
|
attorney general, which action may include direct initiation of |
|
prosecution, with the consent of the appropriate local district or |
|
county attorney, direct initiation of civil litigation, referral to |
|
an appropriate United States attorney, a district attorney, or a |
|
county attorney, or referral to a collections agency for initiation |
|
of civil litigation or other appropriate action; |
|
(2) the office of inspector general to keep detailed |
|
records for cases processed by that office or the office of the |
|
attorney general, including information on the total number of |
|
cases processed and, for each case: |
|
(A) the agency and division to which the case is |
|
referred for investigation; |
|
(B) the date on which the case is referred; and |
|
(C) the nature of the suspected fraud, waste, or |
|
abuse; |
|
(3) the office of inspector general to notify each |
|
appropriate division of the office of the attorney general of each |
|
case referred by the office of inspector general; |
|
(4) the office of the attorney general to ensure that |
|
information relating to each case investigated by that office is |
|
available to each division of the office with responsibility for |
|
investigating suspected fraud, waste, or abuse; |
|
(5) the office of the attorney general to notify the |
|
office of inspector general of each case the attorney general |
|
declines to prosecute or prosecutes unsuccessfully; |
|
(6) representatives of the office of inspector general |
|
and of the office of the attorney general to meet not less than |
|
quarterly to share case information and determine the appropriate |
|
agency and division to investigate each case; and |
|
(7) the office of inspector general and the office of |
|
the attorney general to submit information requested by the |
|
comptroller about each resolved case for the comptroller's use in |
|
improving fraud detection. |
|
(c) The office of inspector general [commission] and the |
|
office of the attorney general shall jointly prepare and submit a |
|
semiannual report to the governor, lieutenant governor, speaker of |
|
the house of representatives, and comptroller concerning the |
|
activities of the office of the attorney general and the office of |
|
inspector general [those agencies] in detecting and preventing |
|
fraud, waste, and abuse under the state Medicaid program or other |
|
program administered by the commission or a health and human |
|
services agency. The report may be consolidated with any other |
|
report relating to the same subject matter the office of inspector |
|
general [commission] or office of the attorney general is required |
|
to submit under other law. |
|
(d) The office of inspector general [commission] and the |
|
office of the attorney general may not assess or collect |
|
investigation and attorney's fees on behalf of any state agency |
|
unless the office of inspector general, the office of the attorney |
|
general, or another [other] state agency collects a penalty, |
|
restitution, or other reimbursement payment to the state. |
|
SECTION 5. Section 531.1031(a)(2), Government Code, is |
|
amended to read as follows: |
|
(2) "Participating agency" means: |
|
(A) the Medicaid fraud enforcement divisions of |
|
the office of the attorney general; [and] |
|
(B) each board or agency with authority to |
|
license, register, regulate, or certify a health care professional |
|
or managed care organization that may participate in the state |
|
Medicaid program; and |
|
(C) the office of inspector general. |
|
SECTION 6. Section 531.104(a), Government Code, is amended |
|
to read as follows: |
|
(a) The office of inspector general [commission] and the |
|
attorney general shall execute a memorandum of understanding under |
|
which the office [commission] 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 [commission] shall assist |
|
in performing preliminary investigations and ongoing |
|
investigations for actions prosecuted by the attorney general under |
|
Subchapter C, Chapter 36, Human Resources Code. |
|
SECTION 7. Section 531.105, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.105. FRAUD DETECTION TRAINING. [(a)] The office |
|
of inspector general [commission] shall develop and implement a |
|
program to provide annual training to contractors who process |
|
Medicaid claims and appropriate staff of the health and human |
|
services agencies [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 Texas Department of Health and the Texas Department
|
|
of Human Services, in cooperation with the 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 commission.
The
|
|
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 531.103(c).] |
|
SECTION 8. Sections 531.106(f) and (g), Government Code, |
|
are amended to read as follows: |
|
(f) Cases [The commission shall refer cases] identified by |
|
the technology shall be referred to the [commission's] office of |
|
inspector general [investigations and enforcement] or the office of |
|
the attorney general, 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 commission or the office of inspector general 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 commission shall refer] the |
|
case shall be referred for investigation to the office of inspector |
|
general or the office of the attorney general, as appropriate [to
|
|
the commission 's office of investigations and enforcement]. |
|
SECTION 9. Section 531.1061, Government Code, is amended to |
|
read as follows: |
|
Sec. 531.1061. FRAUD INVESTIGATION TRACKING SYSTEM. (a) |
|
The office of 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) Each [The commission shall require each] health and |
|
human services agency that performs any aspect of the state |
|
Medicaid program shall [to] participate in the implementation and |
|
use of the automated fraud investigation tracking system as |
|
directed by the office. |
|
SECTION 10. Section 531.1062(a), Government Code, is |
|
amended to read as follows: |
|
(a) The office of 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 11. Sections 531.107(a) and (f), 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 inspector general [investigations and enforcement] in |
|
improving the efficiency of fraud investigations and collections. |
|
(f) At least once each fiscal quarter, the [commission's] |
|
office of inspector general [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 12. Sections 531.108 and 531.109, Government Code, |
|
are amended to read as follows: |
|
Sec. 531.108. FRAUD PREVENTION. (a) The [commission's] |
|
office of inspector general [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 office 's [commission's] case management system |
|
or the case management system of a health and human services agency. |
|
(b) The office of inspector general [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 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. |
|
(d) The office of 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. |
|
(e) The office of inspector general [commission] shall |
|
submit to the governor and Legislative Budget Board a semiannual |
|
report on the results of computerized matching of office and |
|
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. |
|
Sec. 531.109. SELECTION AND REVIEW OF CLAIMS. (a) The |
|
office of 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 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 inspector general and the commission shall determine the |
|
types of claims at which office and commission resources for fraud, |
|
waste, and abuse detection should be primarily directed. |
|
SECTION 13. Sections 531.110(a), (c), (d), (e), and (f), |
|
Government Code, are amended to read as follows: |
|
(a) The office of 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 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 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 inspector general [commission], or a |
|
health and human services agency designated by the office |
|
[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 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 14. Section 531.1112, Government Code, is amended |
|
to read as follows: |
|
Sec. 531.1112. STUDY CONCERNING INCREASED USE OF TECHNOLOGY |
|
TO STRENGTHEN FRAUD DETECTION AND DETERRENCE; IMPLEMENTATION. (a) |
|
The commission and the [commission's] office of inspector general |
|
shall jointly study the feasibility of increasing the use of |
|
technology to strengthen the detection and deterrence of fraud in |
|
the state Medicaid program. The study must include the |
|
determination of the feasibility of using technology to verify a |
|
person 's citizenship and eligibility for coverage. |
|
(b) The commission shall implement any methods the |
|
commission and the [commission's] office of inspector general |
|
determine are effective at strengthening fraud detection and |
|
deterrence. |
|
SECTION 15. 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 inspector general [commissioner] shall adopt rules |
|
as necessary to accomplish the purposes of this section. |
|
SECTION 16. Sections 531.114(b) and (g), Government Code, |
|
are amended to read as follows: |
|
(b) If after an investigation the office of 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 inspector general [commission] shall adopt rules as |
|
necessary to implement this section. |
|
SECTION 17. Section 533.005(a), 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 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 the state for any overpayments resulting from fraud, |
|
waste or abuse in the Medicaid program, the child health plan |
|
program, or another government funded program. |
|
(15) 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 |
|
(16) 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 18. Section 533.012(c), Government Code, is amended |
|
to read as follows: |
|
(c) The [commission's] office of 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. |
|
SECTION 19. Section 21.014(b), Human Resources Code, is |
|
amended to read as follows: |
|
(b) The [person employed by the department as] inspector |
|
general appointed under Subchapter R, Chapter 531, Government Code, |
|
shall make reports to and consult with the agency director |
|
[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 inspector general" means the office of |
|
inspector general established under Subchapter R, Chapter 531, |
|
Government Code. |
|
SECTION 21. Section 32.0291, Human Resources Code, is |
|
amended to read as follows: |
|
Sec. 32.0291. PREPAYMENT REVIEWS AND POSTPAYMENT HOLDS. |
|
(a) Notwithstanding any other law, the office of inspector |
|
general or 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 inspector |
|
general [department] may impose a postpayment hold on payment of |
|
future claims submitted by a provider if the office [department] |
|
has prima facie evidence that the provider has committed fraud, |
|
waste, abuse, or wilful misrepresentation regarding a claim for |
|
reimbursement or cost report 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 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 of inspector general |
|
[department] under Subsection (b). The office of inspector general |
|
[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 of inspector general [department] |
|
in imposing the hold is relevant, credible, and material to the |
|
issue of fraud, waste, abuse, or wilful misrepresentation. |
|
(d) The 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 of inspector general [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, WASTE, AND |
|
ABUSE. The inspector general [department] shall adopt reasonable |
|
rules for minimizing the opportunity for fraud, waste, and abuse, |
|
for establishing and maintaining methods for detecting and |
|
identifying situations in which a question of fraud, waste, or |
|
abuse in the program may exist, and for referring cases where fraud, |
|
waste, or abuse appears to exist to the appropriate law enforcement |
|
agencies for prosecution. |
|
SECTION 23. Sections 32.0321(a) through (d), Human |
|
Resources Code, are amended to read as follows: |
|
(a) The office of inspector general [department] by rule may |
|
recommend to the department and the department by rule may require |
|
that each provider of medical assistance in a provider type that has |
|
demonstrated significant potential for fraud, waste, or abuse to |
|
file with the department a surety bond in a reasonable amount. The |
|
office and the department by rule shall each require a provider of |
|
medical assistance to file with the department a surety bond in a |
|
reasonable amount if the office [department] identifies a pattern |
|
of suspected fraud, waste, 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, waste, or abuse. |
|
(b) The bond under Subsection (a) must be payable to the |
|
department to compensate the department for damages resulting from |
|
or penalties or fines imposed in connection with an act of fraud, |
|
waste, or abuse committed by the provider under the medical |
|
assistance program. |
|
(c) Subject to Subsection (d) or (e), the office of |
|
inspector general and the 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 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 inspector general and the 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(a), Human Resources Code, is |
|
amended to read as follows: |
|
(a) The office of 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. |
|
SECTION 25. Section 32.070(d), 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, waste, 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 [the] inspector |
|
general, or the Office of Inspector General in the United States |
|
Department of Health and Human Services. |
|
SECTION 26. Section 33.015(e), 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 inspector general established under |
|
Subchapter R, Chapter 531, Government Code. |
|
SECTION 27. 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 |
|
Board; |
|
(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 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, Insurance Code; |
|
(29) apprehension specialists and inspectors general |
|
commissioned by the Texas Youth Commission as officers under |
|
Sections 61.0451 and 61.0931, Human Resources Code; |
|
(30) officers appointed by the inspector general 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 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; |
|
(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) investigators commissioned by the Texas Juvenile |
|
Probation Commission as officers under Section 141.055, Human |
|
Resources Code; and |
|
(36) officers commissioned by the office of inspector |
|
general established under Subchapter R, Chapter 531, Government |
|
Code. |
|
SECTION 28. Sections 531.102 and 531.1021, Government Code, |
|
are repealed. |
|
SECTION 29. Section 411.086, Government Code, is amended to |
|
read as follows: |
|
Sec. 411.083. DISSEMINATION OF CRIMINAL HISTORY RECORD |
|
INFORMATION. (a) Criminal history record information maintained |
|
by the department is confidential information for the use of the |
|
department and, except as provided by this subchapter, may not be |
|
disseminated by the department. |
|
(b) The department shall grant access to criminal history |
|
record information to: |
|
(1) criminal justice agencies; |
|
(2) noncriminal justice agencies authorized by |
|
federal statute or executive order or by state statute to receive |
|
criminal history record information; |
|
(3) the person who is the subject of the criminal |
|
history record information; |
|
(4) a person working on a research or statistical |
|
project that: |
|
(A) is funded in whole or in part by state funds; |
|
or |
|
(B) meets the requirements of Part 22, Title 28, |
|
Code of Federal Regulations, and is approved by the department; |
|
(5) an individual or an agency that has a specific |
|
agreement with a criminal justice agency to provide services |
|
required for the administration of criminal justice under that |
|
agreement, if the agreement: |
|
(A) specifically authorizes access to |
|
information; |
|
(B) limits the use of information to the purposes |
|
for which it is given; |
|
(C) ensures the security and confidentiality of |
|
the information; and |
|
(D) provides for sanctions if a requirement |
|
imposed under Paragraph (A), (B), or (C) is violated; |
|
(6) an individual or an agency that has a specific |
|
agreement with a noncriminal justice agency to provide services |
|
related to the use of criminal history record information |
|
disseminated under this subchapter, if the agreement: |
|
(A) specifically authorizes access to |
|
information; |
|
(B) limits the use of information to the purposes |
|
for which it is given; |
|
(C) ensures the security and confidentiality of |
|
the information; and |
|
(D) provides for sanctions if a requirement |
|
imposed under Paragraph (A), (B), or (C) is violated; |
|
(7) a county or district clerk's office; [and] |
|
(8) the Office of Court Administration of the Texas |
|
Judicial System; and |
|
(9) officers commissioned by the office of inspector |
|
general established under Subchapter R, Chapter 531, Government |
|
Code. |
|
(c) The department may disseminate criminal history record |
|
information under Subsection (b)(1) only for a criminal justice |
|
purpose. The department may disseminate criminal history record |
|
information under Subsection (b)(2) only for a purpose specified in |
|
the statute or order. The department may disseminate criminal |
|
history record information under Subsection (b)(4), (5), or (6) |
|
only for a purpose approved by the department and only under rules |
|
adopted by the department. The department may disseminate criminal |
|
history record information under Subsection (b)(7) only to the |
|
extent necessary for a county or district clerk to perform a duty |
|
imposed by law to collect and report criminal court disposition |
|
information. Criminal history record information disseminated to a |
|
clerk under Subsection (b)(7) may be used by the clerk only to |
|
ensure that information reported by the clerk to the department is |
|
accurate and complete. The dissemination of information to a clerk |
|
under Subsection (b)(7) does not affect the authority of the clerk |
|
to disclose or use information submitted by the clerk to the |
|
department. The department may disseminate criminal history record |
|
information under Subsection (b)(8) only to the extent necessary |
|
for the office of court administration to perform a duty imposed by |
|
law to compile court statistics or prepare reports. The office of |
|
court administration may disclose criminal history record |
|
information obtained from the department under Subsection (b)(8) in |
|
a statistic compiled by the office or a report prepared by the |
|
office, but only in a manner that does not identify the person who |
|
is the subject of the information. |
|
(d) The department is not required to release or disclose |
|
criminal history record information to any person that is not in |
|
compliance with rules adopted by the department under this |
|
subchapter or rules adopted by the Federal Bureau of Investigation |
|
that relate to the dissemination or use of criminal history record |
|
information. |
|
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 person serving as inspector general |
|
under Section 531.102(a-1), Government Code, on the effective date |
|
of this Act shall serve as the inspector general appointed under |
|
Subchapter R, Chapter 531, Government Code, as added by this Act, |
|
until February 1, 2011, and may be reappointed under Subchapter R, |
|
Chapter 531, if the person has the qualifications required under |
|
that subchapter. |
|
(b) Not later than February 1, 2011, the governor shall |
|
appoint an inspector general for the Office of Inspector General |
|
under Subchapter R, Chapter 531, Government Code, as added by this |
|
Act, to a term expiring February 1, 2013. |
|
SECTION 32. On the effective date of this Act: |
|
(1) all functions, activities, employees, rules, |
|
forms, money, property, contracts, memorandums of understanding, |
|
records, and obligations of the office of inspector general under |
|
Section 531.102(a-1), Government Code, become functions, |
|
activities, employees, rules, forms, money, property, contracts, |
|
memorandums of understanding, records, and obligations of the |
|
Office of Inspector General established under Subchapter R, Chapter |
|
531, Government Code, as added by this Act, without a change in |
|
status; and |
|
(2) all money appropriated or budgeted for the office |
|
of inspector general under Section 531.102(a-1), Government Code, |
|
including money for providing administrative support, is |
|
considered appropriated for the use of the Office of Inspector |
|
General established under Subchapter R, Chapter 531, Government |
|
Code, as added by this Act. |
|
SECTION 33. If before implementing any provision of this |
|
Act a state office or agency determines that a waiver or |
|
authorization from a federal agency is necessary for implementation |
|
of that provision, the office or agency affected by the provision |
|
shall request the waiver or authorization and may delay |
|
implementing that provision until the waiver or authorization is |
|
granted. |
|
SECTION 34. This Act takes effect immediately if it |
|
receives a vote of two-thirds of all the members elected to each |
|
house, as provided by Section 39, Article III, Texas Constitution. |
|
If this Act does not receive the vote necessary for immediate |
|
effect, this Act takes effect September 1, 2009. |