SB 1803, Sen 2nd Rdg, Amnd #F1

(f)(1) If the commission receives a complaint of Medicaid fraud or abuse from any source, the office must conduct a preliminary investigation [~~an integrity review~~] to determine whether there is a sufficient basis to warrant a full investigation. A preliminary investigation [~~An integrity review~~] must begin not later than the 30th day after the date the commission receives a complaint or has reason to believe that fraud or abuse has occurred. A preliminary investigation [~~An integrity review~~] shall be completed not later than the 90th day after it began.

(2) If the findings of a preliminary investigation [~~an integrity review~~] give the office reason to believe that an incident of fraud or abuse involving possible criminal conduct has occurred in the Medicaid program, the office must take the following action, as appropriate, not later than the 30th day after the completion of the preliminary investigation [~~integrity review~~]:

(A) if a provider is suspected of fraud or abuse involving criminal conduct, the office must refer the case to the state's Medicaid fraud control unit, provided that the criminal referral does not preclude the office from continuing its investigation of the provider, which investigation may lead to the imposition of appropriate administrative or civil sanctions; or

(B) if there is reason to believe that a recipient has defrauded the Medicaid program, the office may conduct a full investigation of the suspected fraud.

(4) In SECTION 2 of the bill, in amended Section 531.102(g)(2), Government Code (page 2, line 28), strike "may [~~shall~~]" and substitute "shall".

(5) In SECTION 2 of the bill, in amended Section 531.102(g)(2), Government Code (page 2, line 29), strike "hold on payment of" and substitute "payment hold on [~~payment of~~]".

(6) In SECTION 2 of the bill, in amended Section 531.102(g)(2), Government Code (page 2, lines 36 and 37), strike "hold on payment" and substitute "payment hold [~~on payment~~]".

(7) In SECTION 2 of the bill, in amended Section 531.102(g)(2), Government Code (page 2, line 38), strike "Notwithstanding" and substitute "In addition to".

(8) In SECTION 2 of the bill, in added Section 531.102(g)(2)(A), Government Code (page 2, lines 41 and 42), strike ", if available,".

(9) In SECTION 2 of the bill, in added Section 531.102(g)(2)(A), Government Code (page 2, line 43), between "investigation" and the underlined semicolon, insert "and a representative sample of any documents that form the basis of the hold".

(10) In SECTION 2 of the bill, in amended Section 531.102(g)(3), Government Code (page 2, line 48), strike "hold on payment" and substitute "payment hold [~~on payment~~]".

(11) In SECTION 2 of the bill, in amended Section 531.102(g)(3), Government Code (page 2, line 53), strike "10th" and substitute "30th [~~10th~~]".

(12) In SECTION 2 of the bill, at the end of amended Section 531.102(g)(3), Government Code (page 2, line 65), add the following:

The executive commissioner and the State Office of Administrative Hearings shall jointly adopt rules that require a provider, before a hearing, to advance security for the costs for which the provider is responsible under this subdivision.

(13) In SECTION 2 of the bill, in amended Section 531.102(g)(4), Government Code (page 2, line 67), strike "hold on payment" and substitute "payment hold".

(14) In SECTION 2 of the bill, strike added Section 531.102(g)(5), Government Code (page 3, lines 2 through 32), and substitute the following:

(5) The executive commissioner [~~commission~~] shall adopt rules that allow a provider subject to a [~~hold on~~] payment hold under Subdivision (2), other than a hold requested by the state's Medicaid fraud control unit, to seek an initial informal resolution of the issues identified by the office in the notice provided under that subdivision. A provider must request [~~seek~~] an initial informal resolution meeting under this subdivision not later than the deadline prescribed by Subdivision (3). On receipt of a timely request, the office shall schedule an initial informal resolution meeting not later than the 60th day after the date the office receives the request from the provider, but the office shall schedule the meeting on a later date as determined by the office if requested by the provider. The office shall give notice to the provider of the time and place of the initial informal resolution meeting not later than the 30th day before the date the initial informal resolution meeting is to be held. A provider may request a second informal resolution meeting not later than the 20th day after the date of the initial informal resolution meeting. On receipt of a timely request, the office shall schedule a second informal resolution meeting not later than the 45th day after the date the office receives the request from the provider, but the office shall schedule the meeting on a later date as determined by the office if requested by the provider. The office shall give notice to the provider of the time and place of the second informal resolution meeting not later than the 20th day before the date the second informal resolution meeting is to be held. A provider shall have an opportunity to provide additional information before the second informal resolution meeting for consideration by the office. A provider's decision to seek an informal resolution under this subdivision does not extend the time by which the provider must request an expedited administrative hearing under Subdivision (3). However, a hearing initiated under Subdivision (3) shall be stayed [~~at the office's request~~] until the informal resolution process is completed.

(15) In SECTION 2 of the bill, in added Section 531.102(g)(6), Government Code (page 3, line 35), strike "holds on payment" and insert "payment holds [~~on payment~~]".

(16) In SECTION 2 of the bill, in added Section 531.102(l), Government Code (page 3, line 40), between "Board" and the underlined period, insert ", and who preferably has significant knowledge of the Medicaid program".

(17) In SECTION 2 of the bill, in added Section 531.102(l), Government Code (page 3, line 42), between "of" and "care", insert "medical".

(18) In SECTION 2 of the bill, in added Section 531.102(m), Government Code (page 3, line 46), strike "(m) The" and substitute the following:

(m) The office shall employ a dental director who is a licensed dentist under Subtitle D, Title 3, Occupations Code, and the rules adopted under that subtitle by the State Board of Dental Examiners, and who preferably has significant knowledge of the Medicaid program. The dental director shall ensure that any investigative findings based on the necessity of dental services or the quality of dental care have been reviewed by a qualified expert as described by the Texas Rules of Evidence before the office imposes a payment hold or seeks recoupment of an overpayment, damages, or penalties.

(n) To the extent permitted under federal law, the

(19) In the recital to SECTION 3 of the bill (page 3, line 55), strike "and 531.1201" and substitute "531.1201, and 531.1202".

(20) In SECTION 3 of the bill, in the heading to added Section 531.118, Government Code (page 3, line 57), strike "INTEGRITY REVIEWS OF ALLEGATIONS OF FRAUD" and substitute "PRELIMINARY INVESTIGATIONS OF ALLEGATIONS OF FRAUD OR ABUSE".

(21) In SECTION 3 of the bill, in added Section 531.118(a), Government Code (page 3, line 59), between "fraud" and "against", insert "or abuse".

(22) In SECTION 3 of the bill, in added Section 531.118(a), Government Code (page 3, line 60), between "fraud" and "was", insert "or abuse".

(23) In SECTION 3 of the bill, strike added Section 531.118(b), Government Code (page 3, lines 63 through 69), and substitute the following:

(b) If the commission receives an allegation of fraud or abuse against a Medicaid provider from any source, the office must conduct a preliminary investigation of each allegation of fraud or abuse to determine whether there is sufficient basis to warrant a full investigation. A preliminary investigation must begin not later than the 30th day after the date the commission receives or identifies an allegation of fraud or abuse.

(24) In SECTION 3 of the bill, in added Section 531.118(c), Government Code (page 4, line 1), strike "An integrity review" and substitute "A preliminary investigation".

(25) In SECTION 3 of the bill, in added Section 531.118(d), Government Code (page 4, line 13), between "completed" and the underlined period, insert ", or until the Medicaid fraud control unit, other law enforcement agency, or other prosecuting authorities determine that there is insufficient evidence of fraud by the provider".

(26) In SECTION 3 of the bill, in added Section 531.119, Government Code (page 4, line 28), strike "description, in plain English, of the" and substitute "description in plain English of, and a video explaining, the".

(27) In SECTION 3 of the bill, in added Section 531.119, Government Code (page 4, line 30), strike "hold on a payment to" and substitute "payment hold on".

(28) In SECTION 3 of the bill, in added Section 531.120(a), Government Code (page 4, lines 37 and 38), strike "if available," and substitute "a representative sample of any documents that form the basis of the overpayment,".

(29) In SECTION 3 of the bill, in added Section 531.120(a), Government Code (page 4, line 38), strike "the calculation of" and substitute "calculation of the".

(30) In SECTION 3 of the bill, in added Section 531.120(a), Government Code (page 4, line 41), strike "an informal review" and substitute "the provider's right to request informal resolution meetings under this section".

(31) In SECTION 3 of the bill, strike added Section 531.120(b), Government Code (page 4, lines 43 through 63), and substitute the following:

(b) A provider must request an initial informal resolution meeting under this section not later than the 30th day after the date the provider receives notice under Subsection (a). On receipt of a timely request, the office shall schedule an initial informal resolution meeting not later than the 60th day after the date the office receives the request from the provider, but the office shall schedule the meeting on a later date as determined by the office if requested by the provider. The office shall give notice to the provider of the time and place of the initial informal resolution meeting not later than the 30th day before the date the initial informal resolution meeting is to be held. A provider may request a second informal resolution meeting not later than the 20th day after the date of the initial informal resolution meeting. On receipt of a timely request, the office shall schedule a second informal resolution meeting not later than the 45th day after the date the office receives the request from the provider, but the office shall schedule the meeting on a later date as determined by the office if requested by the provider. The office shall give notice to the provider of the time and place of the second informal resolution meeting not later than the 20th day before the date the second informal resolution meeting is to be held. A provider shall have an opportunity to provide additional information before the second informal resolution meeting for consideration by the office.

(32) In SECTION 3 of the bill, in added Section 531.1201(a), Government Code (page 4, line 67), strike "receives notice under Section 531.120(a)" and substitute "is notified that the commission or the commission's office of inspector general will seek to recover an overpayment or debt from the provider".

(33) In SECTION 3 of the bill, at the end of added Section 531.1201(a), Government Code (page 5, line 20), add the following:

(34) In SECTION 3 of the bill, immediately following added Section 531.1201, Government Code (page 5, between lines 25 and 26), add the following:

Sec. 531.1202. PRESENCE OF NEUTRAL THIRD PARTY AT INFORMAL RESOLUTION MEETINGS. The commission shall employ a person whose salary is paid by the commission and who is independent of the commission's office of inspector general to attend the informal resolution meetings held under Sections 531.102(g)(5) and 531.120(b) as a neutral third-party observer. The person shall report to the executive commissioner on the proceedings and outcome of each informal resolution meeting.

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