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A BILL TO BE ENTITLED
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AN ACT
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relating to the recoupment of payments on certain provider claims |
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made under the Medicaid program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter B, Chapter 32, Human Resources Code, |
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is amended by adding Sections 32.0631 and 32.0632 to read as |
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follows: |
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Sec. 32.0631. POLICIES RELATED TO RECOUPMENT OF PAYMENTS. |
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(a) Notwithstanding any other law the commission shall, subject to |
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Subsection (b), develop and implement policies to prevent |
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recoupment of an improper payment that was made to a provider for a |
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claim for medical services made under the medical assistance |
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program if the provider: |
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(1) actually provided a medical service reimbursable |
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under the medical assistance program; and |
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(2) submitted a clean claim as required under the |
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medical assistance program. |
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(b) The policies developed under Subsection (a) must: |
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(1) allow the recoupment of an improper payment in the |
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case of fraud or abuse; and |
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(2) require that when recoupment is allowed, the |
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amount of a recouped payment may be no greater than the difference |
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between the payment amount made to the provider that is subject to |
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recoupment and the reimbursement rate in effect on the date the |
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service was provided. |
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(c) To reduce the incidence of improper payments under the |
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medical assistance program, the commission shall develop and |
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implement methods to improve communication between: |
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(1) the commission; |
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(2) providers under the program; |
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(3) entities with which the commission contracts to |
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administer claims under the program; and |
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(4) managed care organizations with which the |
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commission contracts to provide medical services to recipients |
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under the program. |
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(d) The methods to improve communication under Subsection |
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(c) must include requirements to provide necessary information to a |
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provider regarding: |
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(1) how, and to whom, the provider must submit a clean |
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claim; and |
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(2) how the provider may file a complaint with the |
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commission regarding a payment dispute, including a complaint that |
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may be filed after the provider has exhausted all rights to appeal. |
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Sec. 32.0632. PROCESSES AND IMPROVEMENTS RELATED TO |
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OVERPAYMENT OF CLAIMS. (a) The commission shall conduct separate |
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studies to: |
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(1) evaluate the feasibility of implementing a process |
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that allows an entity with which the commission contracts to |
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administer claims under the medical assistance program, or a |
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managed care organization with which the commission contracts to |
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provide services to recipients under the medical assistance |
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program, that makes an improper payment on a claim that is subject |
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to Section 32.0631, to have a right of subrogation against another |
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entity, including a managed care organization, that is or would |
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have been responsible for payment of the claim had the claim been |
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properly filed with that entity; and |
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(2) identify improvements that should be made to |
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eligibility determination processes and other administrative |
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procedures in order to reduce the incidence of retroactive |
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disenrollment from the medical assistance program that can result |
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in improper payments. |
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(b) If, as a result of each study conducted under this |
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section, the commission determines that implementation of the |
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studied process or improvements, as applicable, would be feasible |
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and cost-effective to implement, the commission shall, |
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notwithstanding any other law, implement the process or |
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improvements. If the commission implements the process or |
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improvements, the commission shall modify contracts with an entity |
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with which the commission contracts to administer claims and |
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managed care organizations to the extent possible and as necessary |
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for that implementation. |
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(c) Not later than December 1, 2016, the commission shall |
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submit a report to each standing committee of the senate and house |
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of representatives having primary jurisdiction over the medical |
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assistance program detailing the results of each study conducted |
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under this section and, if the commission implemented the |
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applicable process or improvements in accordance with Subsection |
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(b), an analysis of the effectiveness of the implementation in |
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reducing overpayments. This subsection expires September 1, 2017. |
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SECTION 2. Section 32.0631, Human Resources Code, as added |
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by this Act, applies only to improper payments for claims made under |
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the medical assistance program under Chapter 32, Human Resources |
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Code, that are made on or after the effective date of this Act. A |
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claim made before the effective date of this Act is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 3. 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 4. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2015. |