83R2900 EES-F

By: Eiland H.B. No. 1924

A BILL TO BE ENTITLED

AN ACT

relating to the implementation of certain technology in the Health and Human Services Commission's claims processing procedures to prevent fraud, waste, and abuse in the Medicaid and child health plan programs.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subchapter C, Chapter 531, Government Code, is amended by adding Section 531.118 to read as follows:

Sec. 531.118. IMPLEMENTATION OF TECHNOLOGY SOLUTIONS IN CLAIMS PROCESSING PROCEDURES TO PREVENT FRAUD, WASTE, AND ABUSE. (a) To reduce fraud, waste, and abuse in the Medicaid and child health plan programs, the commission shall implement in the Medicaid fee-for-service and managed care models and the child health plan program prepayment fraud prevention solutions to detect and prevent fraud, waste, and abuse before paying provider claims. The solutions must include the implementation of:

(1) provider data verification and screening technology in the commission's claims processing procedures in order for the commission to verify billing and other information submitted by a provider with information maintained about the provider by the commission in a continually updated provider information database for the purpose of:

(A) automating the commission's procedures for reviewing claims;

(B) identifying and preventing inappropriate payments to a deceased, sanctioned, or retired provider or a provider who is practicing with an expired license; and

(C) identifying and preventing the payment of a provider at the wrong address; and

(2) predictive modeling and analytics technology in the commission's claims processing procedures in order for the commission to have access to comprehensive and accurate information about Medicaid and child health plan program providers and recipients and the geographic distribution of those providers and recipients for the purpose of:

(A) identifying and analyzing billing and utilization patterns that indicate a high risk for fraudulent activity;

(B) analyzing claims before payment to minimize disruptions to the commission's claims processing procedures and to speed the resolution of claims;

(C) prioritizing claims that likely involve fraud, waste, or abuse for additional review before payment; and

(D) preventing the payment of claims that potentially involve fraud, waste, or abuse until the claims have been verified as valid.

(b) The commission shall collect outcome information relating to provider reimbursement claims previously paid by the commission to enhance the predictive modeling and analytics technology described in Subsection (a)(2).

(c) The commission shall contract with an entity to initially implement and maintain the data verification and screening technology and the predictive modeling and analytics technology described in Subsection (a). To the extent possible, the commission shall pay for that technology through savings achieved by the implementation of the technology. The commission may pay an entity that contracts with the commission to implement or maintain the technology according to a percentage of achieved savings model, a per Medicaid or child health plan program recipient per month model, a per transaction model, a case-rate model, or a blended model. The commission may specify in a contract with an entity under this section certain performance measures that must be met before the entity receives payment under the contract.

SECTION 2. 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 3. This Act takes effect September 1, 2013.