By: J. Davis of Harris H.B. No. 1720
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to improving health care provider accountability and
  efficiency under the child health plan and Medicaid programs.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter B, Chapter 531, Government Code, is
  amended by adding Section 531.024161 to read as follows:
         Sec. 531.024161.  REIMBURSEMENT CLAIMS FOR CERTAIN MEDICAID
  OR CHIP SERVICES INVOLVING SUPERVISED PROVIDERS. (a)  If a
  provider, including a nurse practitioner or physician assistant,
  under the Medicaid or child health plan program provides a referral
  for or orders health care services for a recipient or enrollee, as
  applicable, at the direction or under the supervision of another
  provider, and the referral or order is based on the supervised
  provider's evaluation of the recipient or enrollee, the names and
  associated national provider identifier numbers of the supervised
  provider and the supervising provider must be included on any claim
  for reimbursement submitted by a provider based on the referral or
  order. For purposes of this section, "national provider
  identifier" means the national provider identifier required under
  Section 1128J(e), Social Security Act (42 U.S.C. Section
  1320a-7k(e)).
         (b)  The executive commissioner shall adopt rules necessary
  to implement this section.
         SECTION 2.  Subchapter C, Chapter 531, Government Code, is
  amended by adding Sections 531.1131, 531.1132, and 531.117 to read
  as follows:
         Sec. 531.1131.  FRAUD AND ABUSE RECOVERY BY CERTAIN PERSONS;
  RETENTION OF RECOVERED AMOUNTS. (a) If a managed care
  organization's special investigative unit under Section
  531.113(a)(1) or the entity with which the managed care
  organization contracts under Section 531.113(a)(2) discovers fraud
  or abuse in the Medicaid program or the child health plan program,
  the unit or entity shall:
               (1)  immediately notify the commission's office of
  inspector general;
               (2)  subject to Subsection (b), begin payment recovery
  efforts; and
               (3)  ensure that any payment recovery efforts in which
  the organization engages are in accordance with applicable rules
  adopted by the executive commissioner.
         (b)  If the amount sought to be recovered under Subsection
  (a)(2) exceeds $100,000, the managed care organization's special
  investigative unit or contracted entity described by Subsection (a)
  may not engage in payment recovery efforts if, not later than the
  10th business day after the date the unit or entity notified the
  commission's office of inspector general under Subsection (a)(1),
  the unit or entity receives a notice from the office indicating that
  the unit or entity is not authorized to proceed with recovery
  efforts.
         (c)  A managed care organization may retain any money
  recovered under Subsection (a)(2) by the organization's special
  investigative unit or contracted entity described by Subsection
  (a).
         (d)  A managed care organization shall submit a quarterly
  report to the commission's office of inspector general detailing
  the amount of money recovered under Subsection (a)(2).
         (e)  The executive commissioner shall adopt rules necessary
  to implement this section, including rules establishing due process
  procedures that must be followed by managed care organizations when
  engaging in payment recovery efforts as provided by this section.
         Sec. 531.1132.  ANNUAL REPORT ON CERTAIN FRAUD AND ABUSE
  RECOVERIES.  Not later than December 1 of each year, the commission
  shall prepare and submit a report to the legislature relating to the
  amount of money recovered during the preceding 12-month period as a
  result of investigations and recovery efforts made under Sections
  531.113 and 531.1131 by special investigative units or entities
  with which a managed care organization contracts under Section
  531.113(a)(2). The report must specify the amount of money retained
  by each managed care organization under Section 531.1131(c).
         Sec. 531.117.  RECOVERY AUDIT CONTRACTORS. To the extent
  required under Section 1902(a)(42), Social Security Act (42 U.S.C.
  Section 1396a(a)(42)), the commission shall establish a program
  under which the commission contracts with one or more recovery
  audit contractors for purposes of identifying underpayments and
  overpayments under the Medicaid program and recovering the
  overpayments.
         SECTION 3.  Subchapter D, Chapter 62, Health and Safety
  Code, is amended by adding Section 62.1561 to read as follows:
         Sec. 62.1561.  PROHIBITION OF CERTAIN HEALTH CARE PROVIDERS.  
  The executive commissioner of the commission shall adopt rules for
  prohibiting a person from participating in the child health plan
  program as a health care provider for a reasonable period, as
  determined by the executive commissioner, if the person:
               (1)  fails to repay overpayments under the program; or
               (2)  owns, controls, manages, or is otherwise
  affiliated with and has financial, managerial, or administrative
  influence over a provider who has been suspended or prohibited from
  participating in the program.
         SECTION 4.  Section 32.047, Human Resources Code, is amended
  to read as follows:
         Sec. 32.047.  PROHIBITION OF CERTAIN HEALTH CARE SERVICE
  PROVIDERS. (a) A person is permanently prohibited from providing
  or arranging to provide health care services under the medical
  assistance program if:
               (1)  the person is convicted of an offense arising from
  a fraudulent act under the program; and
               (2)  the person's fraudulent act results in injury to an
  elderly person, as defined by Section 48.002(a)(1) [48.002(1)], a
  disabled person, as defined by Section 48.002(a)(8)(A) 
  [48.002(8)(A)], or a person younger than 18 years of age.
         (b)  The executive commissioner of the Health and Human
  Services Commission shall adopt rules for prohibiting a person from
  participating in the medical assistance program as a health care
  provider for a reasonable period, as determined by the executive
  commissioner, if the person:
               (1)  fails to repay overpayments under the program; or
               (2)  owns, controls, manages, or is otherwise
  affiliated with and has financial, managerial, or administrative
  influence over a provider who has been suspended or prohibited from
  participating in the program.
         SECTION 5.  Subchapter B, Chapter 32, Human Resources Code,
  is amended by adding Section 32.068 to read as follows:
         Sec. 32.068.  IN-PERSON EVALUATION REQUIRED FOR CERTAIN
  SERVICES. (a) A medical assistance provider may order or otherwise
  authorize the provision of home health services for a recipient
  only if the provider has conducted an in-person evaluation of the
  recipient within the six-month period preceding the date the order
  or other authorization was issued.
         (b)  A physician, physician assistant, nurse practitioner,
  clinical nurse specialist, or certified nurse-midwife that orders
  or otherwise authorizes the provision of durable medical equipment
  for a recipient in accordance with Chapter 157, Occupations Code,
  and other applicable law, including rules, must certify on the
  order or other authorization that the person conducted an in-person
  evaluation of the recipient within the six-month period preceding
  the date the order or other authorization was issued.
         (c)  The executive commissioner of the Health and Human
  Services Commission shall adopt rules necessary to implement this
  section.
         SECTION 6.  Section 531.1131, Government Code, as added by
  this Act, applies to the investigation of a fraudulent Medicaid or
  child health plan program claim or other program abuse that
  commences on or after the effective date of this Act. An
  investigation that commences before the effective date of this Act
  is governed by the law in effect when the investigation commenced,
  and the former law is continued in effect for that purpose.
         SECTION 7.  If before implementing any provision of this Act
  a state agency determines that a waiver or authorization from a
  federal agency is necessary for implementation of that provision,
  the 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 8.  This Act takes effect September 1, 2011.