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A BILL TO BE ENTITLED
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AN ACT
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relating to improving health care provider accountability and |
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efficiency under the child health plan and Medicaid programs. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter B, Chapter 531, Government Code, is |
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amended by adding Section 531.024161 to read as follows: |
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Sec. 531.024161. REIMBURSEMENT CLAIMS FOR CERTAIN MEDICAID |
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OR CHIP SERVICES INVOLVING SUPERVISED PROVIDERS. (a) If a |
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provider, including a nurse practitioner or physician assistant, |
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under the Medicaid or child health plan program provides a referral |
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for or orders health care services for a recipient or enrollee, as |
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applicable, at the direction or under the supervision of another |
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provider, and the referral or order is based on the supervised |
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provider's evaluation of the recipient or enrollee, the name and |
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associated national provider identifier number of the supervised |
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provider must be included on any claim for reimbursement submitted |
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by a provider based on the referral or order. For purposes of this |
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section, "national provider identifier" means the national |
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provider identifier required under Section 1128J(e), Social |
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Security Act (42 U.S.C. Section 1320a-7k(e)). |
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(b) The executive commissioner shall adopt rules necessary |
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to implement this section. |
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SECTION 2. Subchapter C, Chapter 531, Government Code, is |
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amended by adding Sections 531.1131 and 531.117 to read as follows: |
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Sec. 531.1131. FRAUD AND ABUSE RECOVERY BY CERTAIN PERSONS; |
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RETENTION OF RECOVERED AMOUNTS. (a) If a managed care |
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organization's special investigative unit under Section |
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531.113(a)(1) or the entity with which the managed care |
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organization contracts under Section 531.113(a)(2) discovers fraud |
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or abuse in the Medicaid program or the child health plan program, |
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the unit or entity shall: |
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(1) immediately notify the commission's office of |
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inspector general; and |
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(2) subject to Subsection (b), begin payment recovery |
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efforts. |
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(b) If the amount sought to be recovered under Subsection |
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(a)(2) exceeds $200,000, the managed care organization's special |
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investigative unit or contracted entity described by Subsection (a) |
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may not engage in payment recovery efforts if, not later than the |
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10th day after the date the unit or entity notified the commission's |
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office of inspector general under Subsection (a)(1), the unit or |
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entity receives a notice from the office indicating that the unit or |
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entity is not authorized to proceed with recovery efforts. |
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(c) A managed care organization may retain any money |
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recovered under Subsection (a)(2) by the organization's special |
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investigative unit or contracted entity described by Subsection |
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(a). |
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(d) A managed care organization shall submit a quarterly |
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report to the commission's office of inspector general detailing |
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the amount of money recovered under Subsection (a)(2). |
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(e) The executive commissioner shall adopt rules necessary |
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to implement this section. |
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Sec. 531.117. RECOVERY AUDIT CONTRACTORS. To the extent |
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required under Section 1902(a)(42), Social Security Act (42 U.S.C. |
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Section 1396a(a)(42)), the commission shall establish a program |
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under which the commission contracts with one or more recovery |
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audit contractors for purposes of identifying underpayments and |
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overpayments under the Medicaid program and recovering the |
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overpayments. |
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SECTION 3. Subchapter D, Chapter 62, Health and Safety |
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Code, is amended by adding Section 62.1561 to read as follows: |
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Sec. 62.1561. PROHIBITION OF CERTAIN HEALTH CARE PROVIDERS. |
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The executive commissioner of the commission shall adopt rules for |
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prohibiting a person from participating in the child health plan |
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program as a health care provider for a reasonable period, as |
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determined by the executive commissioner, if the person: |
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(1) fails to repay overpayments under the program; or |
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(2) owns, controls, manages, or is otherwise |
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affiliated with a provider who has been suspended or prohibited |
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from participating in the program. |
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SECTION 4. Section 32.047, Human Resources Code, is amended |
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to read as follows: |
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Sec. 32.047. PROHIBITION OF CERTAIN HEALTH CARE SERVICE |
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PROVIDERS. (a) A person is permanently prohibited from providing |
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or arranging to provide health care services under the medical |
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assistance program if: |
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(1) the person is convicted of an offense arising from |
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a fraudulent act under the program; and |
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(2) the person's fraudulent act results in injury to an |
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elderly person, as defined by Section 48.002(1), a disabled person, |
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as defined by Section 48.002(8)(A), or a person younger than 18 |
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years of age. |
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(b) The executive commissioner of the Health and Human |
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Services Commission shall adopt rules for prohibiting a person from |
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participating in the medical assistance program as a health care |
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provider for a reasonable period, as determined by the executive |
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commissioner, if the person: |
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(1) fails to repay overpayments under the program; or |
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(2) owns, controls, manages, or is otherwise |
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affiliated with a provider who has been suspended or prohibited |
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from participating in the program. |
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SECTION 5. Subchapter B, Chapter 32, Human Resources Code, |
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is amended by adding Section 32.068 to read as follows: |
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Sec. 32.068. IN-PERSON EVALUATION REQUIRED FOR CERTAIN |
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SERVICES. (a) A medical assistance provider may order or otherwise |
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authorize the provision of home health services for a recipient |
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only if the provider has conducted an in-person evaluation of the |
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recipient within the six-month period preceding the date the order |
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or other authorization was issued. |
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(b) A physician, physician assistant, nurse practitioner, |
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clinical nurse specialist, or certified nurse-midwife that orders |
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or otherwise authorizes the provision of durable medical equipment |
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for a recipient must certify on the order or other authorization |
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that the person conducted an in-person evaluation of the recipient |
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within the six-month period preceding the date the order or other |
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authorization was issued. |
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(c) The executive commissioner of the Health and Human |
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Services Commission shall adopt rules necessary to implement this |
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section. |
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SECTION 6. Section 531.1131, Government Code, as added by |
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this Act, applies to the investigation of a fraudulent Medicaid or |
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child health plan program claim or other program abuse that |
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commences on or after the effective date of this Act. An |
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investigation that commences before the effective date of this Act |
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is governed by the law in effect when the investigation commenced, |
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and the former law is continued in effect for that purpose. |
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SECTION 7. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 8. This Act takes effect September 1, 2011. |