S.B. No. 207
 
 
 
 
AN ACT
  relating to the authority and duties of the office of inspector
  general of the Health and Human Services Commission.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 531.1011(4), Government Code, is amended
  to read as follows:
               (4)  "Fraud" means an intentional deception or
  misrepresentation made by a person with the knowledge that the
  deception could result in some unauthorized benefit to that person
  or some other person[, including any act that constitutes fraud
  under applicable federal or state law]. The term does not include
  unintentional technical, clerical, or administrative errors.
         SECTION 2.  Section 531.102, Government Code, is amended by
  amending Subsections (g) and (k), amending Subsection (f) as
  amended by S.B. No. 219, Acts of the 84th Legislature, Regular
  Session, 2015, and adding Subsections (a-2), (a-3), (a-4), (a-5),
  (a-6), (f-1), (p), (q), (r), (s), (t), (u), (v), and (w) to read as
  follows:
         (a-2)  The executive commissioner shall work in consultation
  with the office whenever the executive commissioner is required by
  law to adopt a rule or policy necessary to implement a power or duty
  of the office, including a rule necessary to carry out a
  responsibility of the office under Subsection (a).
         (a-3)  The executive commissioner is responsible for
  performing all administrative support services functions necessary
  to operate the office in the same manner that the executive
  commissioner is responsible for providing administrative support
  services functions for the health and human services system,
  including functions of the office related to the following:
               (1)  procurement processes;
               (2)  contracting policies;
               (3)  information technology services;
               (4)  legal services;
               (5)  budgeting; and
               (6)  personnel and employment policies.
         (a-4)  The commission's internal audit division shall
  regularly audit the office as part of the commission's internal
  audit program and shall include the office in the commission's risk
  assessments.
         (a-5)  The office shall closely coordinate with the
  executive commissioner and the relevant staff of health and human
  services system programs that the office oversees in performing
  functions relating to the prevention of fraud, waste, and abuse in
  the delivery of health and human services and the enforcement of
  state law relating to the provision of those services, including
  audits, utilization reviews, provider education, and data
  analysis.
         (a-6)  The office shall conduct investigations independent
  of the executive commissioner and the commission but shall rely on
  the coordination required by Subsection (a-5) to ensure that the
  office has a thorough understanding of the health and human
  services system for purposes of knowledgeably and effectively
  performing the office's duties under this section and any other
  law.
         (f)(1)  If the commission receives a complaint or allegation
  of Medicaid fraud or abuse from any source, the office must conduct
  a preliminary investigation as provided by Section 531.118(c) to
  determine whether there is a sufficient basis to warrant a full
  investigation.  A preliminary investigation must begin not later
  than the 30th day, and be completed not later than the 45th day,
  after the date the commission receives a complaint or allegation or
  has reason to believe that fraud or abuse has occurred.  [A
  preliminary investigation shall be completed not later than the
  90th day after it began.]
               (2)  If the findings of a preliminary investigation
  give the office reason to believe that an incident of fraud or abuse
  involving possible criminal conduct has occurred in Medicaid, the
  office must take the following action, as appropriate, not later
  than the 30th day after the completion of the preliminary
  investigation:
                     (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 Medicaid, the office may conduct a full
  investigation of the suspected fraud, subject to Section
  531.118(c).
         (f-1)  The office shall complete a full investigation of a
  complaint or allegation of Medicaid fraud or abuse against a
  provider not later than the 180th day after the date the full
  investigation begins unless the office determines that more time is
  needed to complete the investigation. Except as otherwise provided
  by this subsection, if the office determines that more time is
  needed to complete the investigation, the office shall provide
  notice to the provider who is the subject of the investigation
  stating that the length of the investigation will exceed 180 days
  and specifying the reasons why the office was unable to complete the
  investigation within the 180-day period.  The office is not
  required to provide notice to the provider under this subsection if
  the office determines that providing notice would jeopardize the
  investigation. 
         (g)(1)  Whenever the office learns or has reason to suspect
  that a provider's records are being withheld, concealed, destroyed,
  fabricated, or in any way falsified, the office shall immediately
  refer the case to the state's Medicaid fraud control
  unit.  However, such 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.
               (2)  As [In addition to other instances] authorized
  under state and [or] federal law, and except as provided by
  Subdivisions (8) and (9), the office shall impose without prior
  notice a payment hold on claims for reimbursement submitted by a
  provider only to compel production of records, when requested by
  the state's Medicaid fraud control unit, or on the determination
  that a credible allegation of fraud exists, subject to Subsections
  (l) and (m), as applicable.  The payment hold is a serious
  enforcement tool that the office imposes to mitigate ongoing
  financial risk to the state. A payment hold imposed under this
  subdivision takes effect immediately. The office must notify the
  provider of the payment hold in accordance with 42 C.F.R. Section
  455.23(b) and, except as provided by that regulation, not later
  than the fifth day after the date the office imposes the payment
  hold.  In addition to the requirements of 42 C.F.R. Section
  455.23(b), the notice of payment hold provided under this
  subdivision must also include:
                     (A)  the specific basis for the hold, including
  identification of the claims supporting the allegation at that
  point in the investigation, [and] a representative sample of any
  documents that form the basis for the hold, and a detailed summary
  of the office's evidence relating to the allegation; [and]
                     (B)  a description of administrative and judicial
  due process rights and remedies, including the provider's option 
  [right] to seek informal resolution, the provider's right to seek a
  formal administrative appeal hearing, or that the provider may seek 
  both; and
                     (C)  a detailed timeline for the provider to
  pursue the rights and remedies described in Paragraph (B).
               (3)  On timely written request by a provider subject to
  a payment hold under Subdivision (2), other than a hold requested by
  the state's Medicaid fraud control unit, the office shall file a
  request with the State Office of Administrative Hearings for an
  expedited administrative hearing regarding the hold not later than
  the third day after the date the office receives the provider's
  request. The provider must request an expedited administrative
  hearing under this subdivision not later than the 10th [30th] day
  after the date the provider receives notice from the office under
  Subdivision (2).  The State Office of Administrative Hearings shall
  hold the expedited administrative hearing not later than the 45th
  day after the date the State Office of Administrative Hearings
  receives the request for the hearing. In a hearing held under this
  subdivision [Unless otherwise determined by the administrative law
  judge for good cause at an expedited administrative hearing, the
  state and the provider shall each be responsible for]:
                     (A)  the provider and the office are each limited
  to four hours of testimony, excluding time for responding to
  questions from the administrative law judge [one-half of the costs
  charged by the State Office of Administrative Hearings];
                     (B)  the provider and the office are each entitled
  to two continuances under reasonable circumstances [one-half of the
  costs for transcribing the hearing]; and
                     (C)  the office is required to show probable cause
  that the credible allegation of fraud that is the basis of the
  payment hold has an indicia of reliability and that continuing to
  pay the provider presents an ongoing significant financial risk to
  the state and a threat to the integrity of Medicaid [the party's own
  costs related to the hearing, including the costs associated with
  preparation for the hearing, discovery, depositions, and
  subpoenas, service of process and witness expenses, travel
  expenses, and investigation expenses; and
                     [(D)     all other costs associated with the hearing
  that are incurred by the party, including attorney's fees].
               (4)  The office is responsible for the costs of a
  hearing held under Subdivision (3), but a provider is responsible
  for the provider's own costs incurred in preparing for the hearing
  [executive commissioner and the State Office of Administrative
  Hearings shall jointly adopt rules that require a provider, before
  an expedited administrative hearing, to advance security for the
  costs for which the provider is responsible under that
  subdivision].
               (5)  In a hearing held under Subdivision (3), the
  administrative law judge shall decide if the payment hold should
  continue but may not adjust the amount or percent of the payment
  hold. Notwithstanding any other law, including Section
  2001.058(e), the decision of the administrative law judge is final
  and may not be appealed [Following an expedited administrative
  hearing under Subdivision (3), a provider subject to a payment
  hold, other than a hold requested by the state's Medicaid fraud
  control unit, may appeal a final administrative order by filing a
  petition for judicial review in a district court in Travis County].
               (6)  The executive commissioner, in consultation with
  the office, shall adopt rules that allow a provider subject to a
  payment hold under Subdivision (2), other than a hold requested by
  the state's Medicaid fraud control unit, to seek an informal
  resolution of the issues identified by the office in the notice
  provided under that subdivision.  A provider must request an
  initial informal resolution meeting under this subdivision not
  later than the deadline prescribed by Subdivision (3) for
  requesting an expedited administrative hearing.  On receipt of a
  timely request, the office shall decide whether to grant the
  provider's request for an initial informal resolution meeting, and
  if the office decides to grant the request, the office shall
  schedule the [an] initial informal resolution meeting [not later
  than the 60th day after the date the office receives the request,
  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 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 decide whether to
  grant the provider's request for a second informal resolution
  meeting, and if the office decides to grant the request, the office
  shall schedule the [a] second informal resolution meeting [not
  later than the 45th day after the date the office receives the
  request, 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 meeting is to be held].  A provider must 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).  
  The informal resolution process shall run concurrently with the
  administrative hearing process, and the informal resolution
  process shall be discontinued once the State Office of
  Administrative Hearings issues a final determination on the payment
  hold. [However, a hearing initiated under Subdivision (3) shall be
  stayed until the informal resolution process is completed.]
               (7)  The office shall, in consultation with the state's
  Medicaid fraud control unit, establish guidelines under which
  [payment holds or] program exclusions:
                     (A)  may permissively be imposed on a provider; or
                     (B)  shall automatically be imposed on a provider.
               (7-a)  The office shall, in consultation with the
  state's Medicaid fraud control unit, establish guidelines
  regarding the imposition of payment holds authorized under
  Subdivision (2).
               (8)  In accordance with 42 C.F.R. Sections 455.23(e)
  and (f), on the determination that a credible allegation of fraud
  exists, the office may find that good cause exists to not impose a
  payment hold, to not continue a payment hold, to impose a payment
  hold only in part, or to convert a payment hold imposed in whole to
  one imposed only in part, if any of the following are applicable:
                     (A)  law enforcement officials have specifically
  requested that a payment hold not be imposed because a payment hold
  would compromise or jeopardize an investigation;
                     (B)  available remedies implemented by the state
  other than a payment hold would more effectively or quickly protect
  Medicaid funds;
                     (C)  the office determines, based on the
  submission of written evidence by the provider who is the subject of
  the payment hold, that the payment hold should be removed;
                     (D)  Medicaid recipients' access to items or
  services would be jeopardized by a full or partial payment hold
  because the provider who is the subject of the payment hold:
                           (i)  is the sole community physician or the
  sole source of essential specialized services in a community; or 
                           (ii)  serves a large number of Medicaid
  recipients within a designated medically underserved area;
                     (E)  the attorney general declines to certify that
  a matter continues to be under investigation; or 
                     (F)  the office determines that a full or partial
  payment hold is not in the best interests of Medicaid.
               (9)  The office may not impose a payment hold on claims
  for reimbursement submitted by a provider for medically necessary
  services for which the provider has obtained prior authorization
  from the commission or a contractor of the commission unless the
  office has evidence that the provider has materially misrepresented
  documentation relating to those services. 
         (k)  A final report on an audit or investigation is subject
  to required disclosure under Chapter 552.  All information and
  materials compiled during the audit or investigation remain
  confidential and not subject to required disclosure in accordance
  with Section 531.1021(g). A confidential draft report on an audit
  or investigation that concerns the death of a child may be shared
  with the Department of Family and Protective Services. A draft
  report that is shared with the Department of Family and Protective
  Services remains confidential and is not subject to disclosure
  under Chapter 552. 
         (p)  The executive commissioner, in consultation with the
  office, shall adopt rules establishing criteria: 
               (1)  for opening a case;
               (2)  for prioritizing cases for the efficient
  management of the office's workload, including rules that direct
  the office to prioritize:
                     (A)  provider cases according to the highest
  potential for recovery or risk to the state as indicated through the
  provider's volume of billings, the provider's history of
  noncompliance with the law, and identified fraud trends;
                     (B)  recipient cases according to the highest
  potential for recovery and federal timeliness requirements; and
                     (C)  internal affairs investigations according to
  the seriousness of the threat to recipient safety and the risk to
  program integrity in terms of the amount or scope of fraud, waste,
  and abuse posed by the allegation that is the subject of the
  investigation; and  
               (3)  to guide field investigators in closing a case
  that is not worth pursuing through a full investigation.
         (q)  The executive commissioner, in consultation with the
  office, shall adopt rules establishing criteria for determining
  enforcement and punitive actions with regard to a provider who has
  violated state law, program rules, or the provider's Medicaid
  provider agreement that include:
               (1)  direction for categorizing provider violations
  according to the nature of the violation and for scaling resulting
  enforcement actions, taking into consideration:
                     (A)  the seriousness of the violation;
                     (B)  the prevalence of errors by the provider;
                     (C)  the financial or other harm to the state or
  recipients resulting or potentially resulting from those errors;
  and
                     (D)  mitigating factors the office determines
  appropriate; and
               (2)  a specific list of potential penalties, including
  the amount of the penalties, for fraud and other Medicaid
  violations.
         (r)  The office shall review the office's investigative
  process, including the office's use of sampling and extrapolation
  to audit provider records. The review shall be performed by staff
  who are not directly involved in investigations conducted by the
  office.
         (s)  The office shall arrange for the Association of
  Inspectors General or a similar third party to conduct a peer review
  of the office's sampling and extrapolation techniques. Based on
  the review and generally accepted practices among other offices of
  inspectors general, the executive commissioner, in consultation
  with the office, shall by rule adopt sampling and extrapolation
  standards to be used by the office in conducting audits. 
         (t)  At each quarterly meeting of any advisory council
  responsible for advising the executive commissioner on the
  operation of the commission, the inspector general shall submit a
  report to the executive commissioner, the governor, and the
  legislature on:
               (1)  the office's activities;
               (2)  the office's performance with respect to
  performance measures established by the executive commissioner for
  the office;
               (3)  fraud trends identified by the office; and
               (4)  any recommendations for changes in policy to
  prevent or address fraud, waste, and abuse in the delivery of health
  and human services in this state.
         (u)  The office shall publish each report required under
  Subsection (t) on the office's Internet website.
         (v)  In accordance with Section 533.015(b), the office shall
  consult with the executive commissioner regarding the adoption of
  rules defining the office's role in and jurisdiction over, and the
  frequency of, audits of managed care organizations participating in
  Medicaid that are conducted by the office and the commission.
         (w)  The office shall coordinate all audit and oversight
  activities relating to providers, including the development of
  audit plans, risk assessments, and findings, with the commission to
  minimize the duplication of activities. In coordinating activities
  under this subsection, the office shall:
               (1)  on an annual basis, seek input from the commission
  and consider previous audits and on-site visits made by the
  commission for purposes of determining whether to audit a managed
  care organization participating in Medicaid; and
               (2)  request the results of any informal audit or
  on-site visit performed by the commission that could inform the
  office's risk assessment when determining whether to conduct, or
  the scope of, an audit of a managed care organization participating
  in Medicaid.
         SECTION 3.  Section 531.1021(a), Government Code, as amended
  by S.B. No. 219, Acts of the 84th Legislature, Regular Session,
  2015, is amended to read as follows:
         (a)  The office of inspector general may issue [request that
  the executive commissioner or the executive commissioner's
  designee approve the issuance by the office of] a subpoena in
  connection with an investigation conducted by the office. A [If the
  request is approved, the office may issue a] subpoena may be issued
  under this section to compel the attendance of a relevant witness or
  the production, for inspection or copying, of relevant evidence
  that is in this state.
         SECTION 4.  Section 531.1031(a), Government Code, as amended
  by S.B. No. 219, Acts of the 84th Legislature, Regular Session,
  2015, is amended to read as follows:
         (a)  In this section and Sections 531.1032, 531.1033, and
  531.1034:
               (1)  "Health care professional" means a person issued a
  license[, registration, or certification] to engage in a health
  care profession.
               (1-a)  "License" means a license, certificate,
  registration, permit, or other authorization that:
                     (A)  is issued by a licensing authority; and
                     (B)  must be obtained before a person may practice
  or engage in a particular business, occupation, or profession.
               (1-b)  "Licensing authority" means a department,
  commission, board, office, or other agency of the state that issues
  a license.
               (1-c)  "Office" means the commission's office of
  inspector general unless a different meaning is plainly required by
  the context in which the term appears.
               (2)  "Participating agency" means:
                     (A)  the Medicaid fraud enforcement divisions of
  the office of the attorney general;
                     (B)  each licensing authority [board or agency]
  with authority to issue a license to[, register, regulate, or
  certify] a health care professional or managed care organization
  that may participate in Medicaid; and
                     (C)  the [commission's] office [of inspector
  general].
               (3)  "Provider" has the meaning assigned by Section
  531.1011(10)(A).
         SECTION 5.  Subchapter C, Chapter 531, Government Code, is
  amended by adding Sections 531.1032, 531.1033, and 531.1034 to read
  as follows:
         Sec. 531.1032.  OFFICE OF INSPECTOR GENERAL:  CRIMINAL
  HISTORY RECORD INFORMATION CHECK.  (a)  The office and each
  licensing authority that requires the submission of fingerprints
  for the purpose of conducting a criminal history record information
  check of a health care professional shall enter into a memorandum of
  understanding to ensure that only persons who are licensed and in
  good standing as health care professionals participate as providers
  in Medicaid. The memorandum under this section may be combined with
  a memorandum authorized under Section 531.1031(c-1) and must
  include a process by which:
               (1)  the office may confirm with a licensing authority
  that a health care professional is licensed and in good standing for
  purposes of determining eligibility to participate in Medicaid; and
               (2)  the licensing authority immediately notifies the
  office if:
                     (A)  a provider's license has been revoked or
  suspended; or
                     (B)  the licensing authority has taken
  disciplinary action against a provider.
         (b)  The office may not, for purposes of determining a health
  care professional's eligibility to participate in Medicaid as a
  provider, conduct a criminal history record information check of a
  health care professional who the office has confirmed under
  Subsection (a) is licensed and in good standing. This subsection
  does not prohibit the office from performing a criminal history
  record information check of a provider that is required or
  appropriate for other reasons, including for conducting an
  investigation of fraud, waste, or abuse.
         (c)  For purposes of determining eligibility to participate
  in Medicaid and subject to Subsection (d), the office, after
  seeking public input, shall establish and the executive
  commissioner by rule shall adopt guidelines for the evaluation of
  criminal history record information of providers and potential
  providers.  The guidelines must outline conduct, by provider type,
  that may be contained in criminal history record information that
  will result in exclusion of a person from Medicaid as a provider,
  taking into consideration:
               (1)  the extent to which the underlying conduct relates
  to the services provided under Medicaid;
               (2)  the degree to which the person would interact with
  Medicaid recipients as a provider; and
               (3)  any previous evidence that the person engaged in
  fraud, waste, or abuse under Medicaid.
         (d)  The guidelines adopted under Subsection (c) may not
  impose stricter standards for the eligibility of a person to
  participate in Medicaid than a licensing authority described by
  Subsection (a) requires for the person to engage in a health care
  profession without restriction in this state.
         (e)  The office and the commission shall use the guidelines
  adopted under Subsection (c) to determine whether a provider
  participating in Medicaid continues to be eligible to participate
  in Medicaid as a provider.
         (f)  The provider enrollment contractor, if applicable, and
  a managed care organization participating in Medicaid shall defer
  to the office regarding whether a person's criminal history record
  information precludes the person from participating in Medicaid as
  a provider.
         Sec. 531.1033.  MONITORING OF CERTAIN FEDERAL DATABASES.  
  The office shall routinely check appropriate federal databases,
  including databases referenced in 42 C.F.R. Section 455.436, to
  ensure that a person who is excluded from participating in Medicaid
  or in the Medicare program by the federal government is not
  participating as a provider in Medicaid.
         Sec. 531.1034.  TIME TO DETERMINE PROVIDER ELIGIBILITY;
  PERFORMANCE METRICS.  (a)  Not later than the 10th day after the
  date the office receives the complete application of a health care
  professional seeking to participate in Medicaid, the office shall
  inform the commission or the health care professional, as
  appropriate, of the office's determination regarding whether the
  health care professional should be denied participation in Medicaid
  based on:
               (1)  information concerning the licensing status of the
  health care professional obtained as described by Section
  531.1032(a);
               (2)  information contained in the criminal history
  record information check that is evaluated in accordance with
  guidelines adopted under Section 531.1032(c);
               (3)  a review of federal databases under Section
  531.1033;
               (4)  the pendency of an open investigation by the
  office; or
               (5)  any other reason the office determines
  appropriate.
         (b)  Completion of an on-site visit of a health care
  professional during the period prescribed by Subsection (a) is not
  required.
         (c)  The office shall develop performance metrics to measure
  the length of time for conducting a determination described by
  Subsection (a) with respect to applications that are complete when
  submitted and all other applications.
         SECTION 6.  Section 531.113, Government Code, is amended by
  adding Subsection (d-1) and amending Subsection (e) as amended by
  S.B. No. 219, Acts of the 84th Legislature, Regular Session, 2015,
  to read as follows:
         (d-1)  The commission's office of inspector general, in
  consultation with the commission, shall:
               (1)  investigate, including by means of regular audits,
  possible fraud, waste, and abuse by managed care organizations
  subject to this section;
               (2)  establish requirements for the provision of
  training to and regular oversight of special investigative units
  established by managed care organizations under Subsection (a)(1)
  and entities with which managed care organizations contract under
  Subsection (a)(2);
               (3)  establish requirements for approving plans to
  prevent and reduce fraud and abuse adopted by managed care
  organizations under Subsection (b);
               (4)  evaluate statewide fraud, waste, and abuse trends
  in Medicaid and communicate those trends to special investigative
  units and contracted entities to determine the prevalence of those
  trends;
               (5)  assist managed care organizations in discovering
  or investigating fraud, waste, and abuse, as needed; and
               (6)  provide ongoing, regular training to appropriate
  commission and office staff concerning fraud, waste, and abuse in a
  managed care setting, including training relating to fraud, waste,
  and abuse by service providers and recipients.
         (e)  The executive commissioner, in consultation with the
  office, shall adopt rules as necessary to accomplish the purposes
  of this section, including rules defining the investigative role of
  the commission's office of inspector general with respect to the
  investigative role of special investigative units established by
  managed care organizations under Subsection (a)(1) and entities
  with which managed care organizations contract under Subsection
  (a)(2). The rules adopted under this section must specify the
  office's role in:
               (1)  reviewing the findings of special investigative
  units and contracted entities;
               (2)  investigating cases in which the overpayment
  amount sought to be recovered exceeds $100,000; and
               (3)  investigating providers who are enrolled in more
  than one managed care organization.
         SECTION 7.  Section 531.118(b), Government Code, is amended
  to read as follows:
         (b)  If the commission receives an allegation of fraud or
  abuse against a provider from any source, the commission's office
  of inspector general shall conduct a preliminary investigation of
  the allegation to determine whether there is a sufficient basis to
  warrant a full investigation.  A preliminary investigation must
  begin not later than the 30th day, and be completed not later than
  the 45th day, after the date the commission receives or identifies
  an allegation of fraud or abuse.
         SECTION 8.  Section 531.120, Government Code, is amended to
  read as follows:
         Sec. 531.120.  NOTICE AND INFORMAL RESOLUTION OF PROPOSED
  RECOUPMENT OF OVERPAYMENT OR DEBT. (a)  The commission or the
  commission's office of inspector general shall provide a provider
  with written notice of any proposed recoupment of an overpayment or
  debt and any damages or penalties relating to a proposed recoupment
  of an overpayment or debt arising out of a fraud or abuse
  investigation.  The notice must include:
               (1)  the specific basis for the overpayment or debt;
               (2)  a description of facts and supporting evidence;
               (3)  a representative sample of any documents that form
  the basis for the overpayment or debt;
               (4)  the extrapolation methodology;
               (4-a)  information relating to the extrapolation
  methodology used as part of the investigation and the methods used
  to determine the overpayment or debt in sufficient detail so that
  the extrapolation results may be demonstrated to be statistically
  valid and are fully reproducible;
               (5)  the calculation of the overpayment or debt amount;
               (6)  the amount of damages and penalties, if
  applicable; and
               (7)  a description of administrative and judicial due
  process remedies, including the provider's option [right] to seek
  informal resolution, the provider's right to seek a formal
  administrative appeal hearing, or that the provider may seek both.
         (b)  A provider may [must] request an [initial] informal
  resolution meeting under this section, and on [not later than the
  30th day after the date the provider receives notice under
  Subsection (a).   On] receipt of the [a timely] request, the office
  shall schedule the [an initial] informal resolution meeting [not
  later than the 60th day after the date the office receives the
  request, 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 meeting is to be held].  The informal
  resolution process shall run concurrently with the administrative
  hearing process, and the administrative hearing process may not be
  delayed on account of the informal resolution process.  [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, 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 meeting is
  to be held.   A provider must have an opportunity to provide
  additional information before the second informal resolution
  meeting for consideration by the office.]
         SECTION 9.  Sections 531.1201(a) and (b), Government Code,
  are amended to read as follows:
         (a)  A provider must request an appeal under this section not
  later than the 30th [15th] day after the date the provider is
  notified that the commission or the commission's office of
  inspector general will seek to recover an overpayment or debt from
  the provider.  On receipt of a timely written request by a provider
  who is the subject of a recoupment of overpayment or recoupment of
  debt arising out of a fraud or abuse investigation, the office of
  inspector general shall file a docketing request with the State
  Office of Administrative Hearings or the Health and Human Services
  Commission appeals division, as requested by the provider, for an
  administrative hearing regarding the proposed recoupment amount
  and any associated damages or penalties.  The office shall file the
  docketing request under this section not later than the 60th day
  after the date of the provider's request for an administrative
  hearing or not later than the 60th day after the completion of the
  informal resolution process, if applicable.
         (b)  The commission's office of inspector general is
  responsible for the costs of an administrative hearing held under
  Subsection (a), but a provider is responsible for the provider's
  own costs incurred in preparing for the hearing [Unless otherwise
  determined by the administrative law judge for good cause, at any
  administrative hearing under this section before the State Office
  of Administrative Hearings, the state and the provider shall each
  be responsible for:
               [(1)     one-half of the costs charged by the State Office
  of Administrative Hearings;
               [(2)     one-half of the costs for transcribing the
  hearing;
               [(3)     the party's own costs related to the hearing,
  including the costs associated with preparation for the hearing,
  discovery, depositions, and subpoenas, service of process and
  witness expenses, travel expenses, and investigation expenses; and
               [(4)     all other costs associated with the hearing that
  are incurred by the party, including attorney's fees].
         SECTION 10.  Section 531.1202, Government Code, is amended
  to read as follows:
         Sec. 531.1202.  RECORD AND CONFIDENTIALITY OF INFORMAL
  RESOLUTION MEETINGS.  (a)  On the written request of the provider,
  the [The] commission shall, at no expense to the provider who
  requested the meeting, provide for an informal resolution meeting
  held under Section 531.102(g)(6) or 531.120(b) to be recorded.  The
  recording of an informal resolution meeting shall be made available
  to the provider who requested the meeting. The commission may not
  record an informal resolution meeting unless the commission
  receives a written request from a provider under this subsection.
         (b)  Notwithstanding Section 531.1021(g) and except as
  provided by this section, an informal resolution meeting held under
  Section 531.102(g)(6) or 531.120(b) is confidential, and any
  information or materials obtained by the commission's office of
  inspector general, including the office's employees or the office's
  agents, during or in connection with an informal resolution
  meeting, including a recording made under Subsection (a), are
  privileged and confidential and not subject to disclosure under
  Chapter 552 or any other means of legal compulsion for release,
  including disclosure, discovery, or subpoena.
         SECTION 11.  Subchapter C, Chapter 531, Government Code, is
  amended by adding Sections 531.1023, 531.1024, 531.1025, and
  531.1203 to read as follows:
         Sec. 531.1023.  COMPLIANCE WITH FEDERAL CODING GUIDELINES.  
  The commission's office of inspector general, including office
  staff and any third party with which the office contracts to perform
  coding services, shall comply with federal coding guidelines,
  including guidelines for diagnosis-related group (DRG) validation
  and related audits.
         Sec. 531.1024.  HOSPITAL UTILIZATION REVIEWS AND AUDITS:  
  PROVIDER EDUCATION PROCESS.  The executive commissioner, in
  consultation with the office, shall by rule develop a process for
  the commission's office of inspector general, including office
  staff and any third party with which the office contracts to perform
  coding services, to communicate with and educate providers about
  the diagnosis-related group (DRG) validation criteria that the
  office uses in conducting hospital utilization reviews and audits.
         Sec. 531.1025.  PERFORMANCE AUDITS AND COORDINATION OF AUDIT
  ACTIVITIES. (a)  Notwithstanding any other law, the commission's
  office of inspector general may conduct a performance audit of any
  program or project administered or agreement entered into by the
  commission or a health and human services agency, including an
  audit related to:
               (1)  contracting procedures of the commission or a
  health and human services agency; or
               (2)  the performance of the commission or a health and
  human services agency.
         (b)  In addition to the coordination required by Section
  531.102(w), the office shall coordinate the office's other audit
  activities with those of the commission, including the development
  of audit plans, the performance of risk assessments, and the
  reporting of findings, to minimize the duplication of audit
  activities. In coordinating audit activities with the commission
  under this subsection, the office shall:
               (1)  seek input from the commission and consider
  previous audits conducted by the commission for purposes of
  determining whether to conduct a performance audit; and
               (2)  request the results of an audit conducted by the
  commission if those results could inform the office's risk
  assessment when determining whether to conduct, or the scope of, a
  performance audit.
         Sec. 531.1203.  RIGHTS OF AND PROVISION OF INFORMATION TO
  PHARMACIES SUBJECT TO CERTAIN AUDITS. (a)  A pharmacy has a right
  to request an informal hearing before the commission's appeals
  division to contest the findings of an audit conducted by the
  commission's office of inspector general or an entity that
  contracts with the federal government to audit Medicaid providers
  if the findings of the audit do not include findings that the
  pharmacy engaged in Medicaid fraud.
         (b)  In an informal hearing held under this section, staff of
  the commission's appeals division, assisted by staff responsible
  for the commission's vendor drug program who have expertise in the
  law governing pharmacies' participation in Medicaid, make the final
  decision on whether the findings of an audit are accurate.  Staff of
  the commission's office of inspector general may not serve on the
  panel that makes the decision on the accuracy of an audit.
         (c)  In order to increase transparency, the commission's
  office of inspector general shall, if the office has access to the
  information, provide to pharmacies that are subject to audit by the
  office, or by an entity that contracts with the federal government
  to audit Medicaid providers, information relating to the
  extrapolation methodology used as part of the audit and the methods
  used to determine whether the pharmacy has been overpaid under
  Medicaid in sufficient detail so that the audit results may be
  demonstrated to be statistically valid and are fully reproducible.
         SECTION 12.  Section 533.015, Government Code, as amended by
  S.B. No. 219, Acts of the 84th Legislature, Regular Session, 2015,
  is amended to read as follows:
         Sec. 533.015.  COORDINATION OF EXTERNAL OVERSIGHT
  ACTIVITIES. (a)  To the extent possible, the commission shall
  coordinate all external oversight activities to minimize
  duplication of oversight of managed care plans under Medicaid and
  disruption of operations under those plans.
         (b)  The executive commissioner, after consulting with the
  commission's office of inspector general, shall by rule define the
  commission's and office's roles in and jurisdiction over, and
  frequency of, audits of managed care organizations participating in
  Medicaid that are conducted by the commission and the commission's
  office of inspector general.
         (c)  In accordance with Section 531.102(w), the commission
  shall share with the commission's office of inspector general, at
  the request of the office, the results of any informal audit or
  on-site visit that could inform that office's risk assessment when
  determining whether to conduct, or the scope of, an audit of a
  managed care organization participating in Medicaid.
         SECTION 13.  The following provisions are repealed:
               (1)  Section 531.1201(c), Government Code; and
               (2)  Section 32.0422(k), Human Resources Code, as
  amended by S.B. No. 219, Acts of the 84th Legislature, Regular
  Session, 2015.
         SECTION 14.  Notwithstanding Section 531.004, Government
  Code, the Sunset Advisory Commission shall conduct a
  special-purpose review of the overall performance of the Health and
  Human Services Commission's office of inspector general.  In
  conducting the review, the Sunset Advisory Commission shall
  particularly focus on the office's investigations and the
  effectiveness and efficiency of the office's processes, as part of
  the Sunset Advisory Commission's review of agencies for the 87th
  Legislature.  The office is not abolished solely because the office
  is not explicitly continued following the review.
         SECTION 15.  Section 531.102, Government Code, as amended by
  this Act, applies only to a complaint or allegation of Medicaid
  fraud or abuse received by the Health and Human Services Commission
  or the commission's office of inspector general on or after the
  effective date of this Act. A complaint or allegation received
  before the effective date of this Act is governed by the law as it
  existed when the complaint or allegation was received, and the
  former law is continued in effect for that purpose.
         SECTION 16.  Not later than March 1, 2016, the executive
  commissioner of the Health and Human Services Commission, in
  consultation with the inspector general of the commission's office
  of inspector general, shall adopt rules necessary to implement the
  changes in law made by this Act to Section 531.102(g)(2),
  Government Code, regarding the circumstances in which a payment
  hold may be placed on claims for reimbursement submitted by a
  Medicaid provider.
         SECTION 17.  As soon as practicable after the effective date
  of this Act, the executive commissioner of the Health and Human
  Services Commission, in consultation with the inspector general of
  the commission's office of inspector general, shall adopt the rules
  establishing the process for communicating with and educating
  providers about diagnosis-related group (DRG) validation criteria
  under Section 531.1024, Government Code, as added by this Act.
         SECTION 18.  Not later than September 1, 2016, the executive
  commissioner of the Health and Human Services Commission shall
  adopt the guidelines required under Section 531.1032(c),
  Government Code, as added by this Act.
         SECTION 19.  Sections 531.120 and 531.1201, Government Code,
  as amended by this Act, apply only to a proposed recoupment of an
  overpayment or debt of which a provider is notified on or after the
  effective date of this Act. A proposed recoupment of an overpayment
  or debt that a provider was notified of before the effective date of
  this Act is governed by the law as it existed when the provider was
  notified, and the former law is continued in effect for that
  purpose.
         SECTION 20.  Not later than March 1, 2016, the executive
  commissioner of the Health and Human Services Commission in
  consultation with the inspector general of the office of inspector
  general shall adopt rules necessary to implement Section 531.1203,
  Government Code, as added by this Act.
         SECTION 21.  Not later than September 1, 2016, the executive
  commissioner of the Health and Human Services Commission shall
  adopt rules required by Section 533.015(b), Government Code, as
  added by this Act.
         SECTION 22.  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 23.  This Act takes effect September 1, 2015.
 
 
 
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
         I hereby certify that S.B. No. 207 passed the Senate on
  April 21, 2015, by the following vote:  Yeas 30, Nays 0;
  May 26, 2015, Senate refused to concur in House amendment and
  requested appointment of Conference Committee; May 27, 2015, House
  granted request of the Senate; May 30, 2015, Senate adopted
  Conference Committee Report by the following vote:  Yeas 30,
  Nays 1.
 
 
  ______________________________
  Secretary of the Senate    
 
         I hereby certify that S.B. No. 207 passed the House, with
  amendment, on May 24, 2015, by the following vote:  Yeas 142,
  Nays 0, two present not voting; May 27, 2015, House granted request
  of the Senate for appointment of Conference Committee;
  May 30, 2015, House adopted Conference Committee Report by the
  following vote:  Yeas 144, Nays 0, two present not voting.
 
 
  ______________________________
  Chief Clerk of the House   
 
 
 
  Approved:
 
  ______________________________ 
             Date
 
 
  ______________________________ 
            Governor