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A BILL TO BE ENTITLED
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AN ACT
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relating to the proof required to impose payment holds in certain |
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cases of alleged fraud by Medicaid providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Sections 531.102(g)(2) and (3), Government Code, |
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are amended to read as follows: |
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(2) As authorized under state and federal law, and |
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except as provided by Subdivisions (8) and (9), the office shall |
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impose without prior notice a payment hold on claims for |
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reimbursement submitted by a provider only to compel production of |
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records, when requested by the state's Medicaid fraud control unit, |
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or on the determination by the office that a credible allegation of |
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fraud exists, subject to Subsections (l) and (m), as applicable. |
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The payment hold is a serious enforcement tool that the office |
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imposes to mitigate ongoing financial risk to the state. A payment |
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hold imposed under this subdivision takes effect immediately. The |
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office must notify the provider of the payment hold in accordance |
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with 42 C.F.R. Section 455.23(b) and, except as provided by that |
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regulation, not later than the fifth day after the date the office |
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imposes the payment hold. In addition to the requirements of 42 |
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C.F.R. Section 455.23(b), the notice of payment hold provided under |
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this subdivision must also include: |
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(A) the specific basis for the hold, including |
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identification of the claims supporting the allegation at that |
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point in the investigation, a representative sample of any |
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documents that form the basis for the hold, and a detailed summary |
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of the office's evidence relating to the allegation; |
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(B) a description of administrative and judicial |
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due process rights and remedies, including the provider's option to |
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seek informal resolution, the provider's right to seek a formal |
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administrative appeal hearing, or that the provider may seek both; |
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and |
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(C) a detailed timeline for the provider to |
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pursue the rights and remedies described in Paragraph (B). |
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(3) On timely written request by a provider subject to |
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a payment hold under Subdivision (2), other than a hold requested by |
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the state's Medicaid fraud control unit, the office shall file a |
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request with the State Office of Administrative Hearings for an |
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expedited administrative hearing regarding the hold not later than |
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the third day after the date the office receives the provider's |
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request. The provider must request an expedited administrative |
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hearing under this subdivision not later than the 10th day after the |
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date the provider receives notice from the office under Subdivision |
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(2). The State Office of Administrative Hearings shall hold the |
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expedited administrative hearing not later than the 45th day after |
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the date the State Office of Administrative Hearings receives the |
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request for the hearing. In a hearing held under this subdivision: |
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(A) the provider and the office are each limited |
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to four hours of testimony, excluding time for responding to |
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questions from the administrative law judge; |
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(B) the provider and the office are each entitled |
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to two continuances under reasonable circumstances; and |
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(C) the office is required to show probable cause |
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that the credible allegation of fraud that is the basis of the |
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payment hold has an indicia of reliability and that continuing to |
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pay the provider presents [an ongoing significant financial risk to
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the state and] a threat to the integrity of Medicaid due to: |
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(i) an ongoing significant financial risk |
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to the state that may result in the loss of $100,000 or more; or |
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(ii) a high probability that a serious |
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threat to the health or safety of a recipient exists or may develop |
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as a result of the provider's conduct. |
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SECTION 2. 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 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. |