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A BILL TO BE ENTITLED
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AN ACT
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relating to investigation of fraud, waste, and abuse in Medicaid |
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managed care by the Health and Human Services Commission's office |
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of inspector general. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.102, Government Code, is amended by |
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adding Subsection (z) to read as follows: |
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(z) The office shall develop a process to allow health care |
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facilities, including hospitals, and other providers to report |
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fraud, waste, and abuse to the office. |
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SECTION 2. Subchapter C, Chapter 531, Government Code, is |
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amended by adding Section 531.1134 to read as follows: |
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Sec. 531.1134. INVESTIGATIONS OF FRAUD, WASTE, AND ABUSE IN |
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MEDICAID MANAGED CARE. (a) In this section: |
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(1) "Medicaid managed care organization" means a |
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managed care organization as defined by Section 533.001 that |
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contracts with the commission under Chapter 533 to provide health |
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care services to Medicaid recipients. |
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(2) "Office" means the commission's office of |
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inspector general. |
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(3) "Potentially preventable event" has the meaning |
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assigned by Section 536.001. |
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(b) The office shall investigate the source of fraud, waste, |
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and abuse in Medicaid managed care contracts and whether the fraud, |
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waste, or abuse was committed by a Medicaid recipient, a provider, a |
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Medicaid managed care organization by denying services, or a |
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hospital by contributing to a potentially preventable event. |
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(c) The commission shall investigate or intervene in the |
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office's investigation of a Medicaid managed care organization that |
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is identified as an outlier among other Medicaid managed care |
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organizations regarding rates of denial of services based on |
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medical necessity. |
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(d) The office shall conduct a fiscal analysis of abuse in |
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quality-based payment outcome and process measures, including |
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potentially preventable events caused by a Medicaid managed care |
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organization's routine denial of care based on medical necessity. |
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(e) The office shall periodically report to the commission |
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the outcomes of Medicaid managed care program investigations |
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conducted by the office. The office may combine the report required |
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by this subsection with a report required by Section 531.102(j). |
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(f) The office shall prepare and submit to the commission |
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and the legislature a quarterly report recommending enforcement |
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actions for the Medicaid managed care program. The commission and |
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the office shall post each report on their respective Internet |
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websites. The office may combine the report required by this |
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subsection with the report required by Section 531.102(t). |
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SECTION 3. 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, 2019. |