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A BILL TO BE ENTITLED
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AN ACT
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relating to claims and overpayment recoupment processes imposed on |
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health care providers under Medicaid. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.024172, Government Code, is amended |
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by amending Subsection (g) and adding Subsections (g-1) and (g-2) |
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to read as follows: |
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(g) The commission may recognize a health care provider's |
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proprietary electronic visit verification system, whether |
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purchased or developed by the provider, as complying with this |
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section and allow the health care provider to use that system for a |
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period determined by the commission if the commission determines |
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that the system: |
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(1) complies with all necessary data submission, |
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exchange, and reporting requirements established under this |
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section; and |
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(2) meets all other standards and requirements |
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established under this section[; and
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[(3)
has been in use by the health care provider since
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at least June 1, 2014]. |
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(g-1) If feasible, the executive commissioner shall ensure |
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a health care provider that uses the provider's proprietary |
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electronic visit verification system recognized under Subsection |
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(g) is reimbursed for the use of that system. |
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(g-2) For purposes of facilitating the use of proprietary |
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electronic visit verification systems by health care providers |
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under Subsection (g) and in consultation with industry stakeholders |
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and the work group established under Subsection (h), the commission |
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or the executive commissioner, as appropriate, shall: |
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(1) develop an open model system that mitigates the |
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administrative burdens identified by providers required to use |
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electronic visit verification; |
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(2) allow providers to use emerging technologies, |
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including Internet-based, mobile telephone-based, and global |
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positioning-based technologies, in the providers' proprietary |
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electronic visit verification systems; and |
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(3) adopt rules governing data submission and provider |
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reimbursement. |
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SECTION 2. Section 531.1131, Government Code, is amended by |
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adding Subsection (f) to read as follows: |
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(f) In adopting rules establishing due process procedures |
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under Subsection (e), the executive commissioner shall require that |
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a managed care organization or an entity with which the managed care |
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organization contracts under Section 531.113(a)(2) that engages in |
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payment recovery efforts in accordance with this section and |
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Section 531.1135 provide: |
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(1) written notice to a provider required to use |
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electronic visit verification of the organization's intent to |
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recoup overpayments in accordance with Section 531.1135; and |
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(2) a provider described by Subdivision (1) at least |
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60 days to cure any defect in a claim before the organization may |
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begin any efforts to collect overpayments. |
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SECTION 3. Subchapter C, Chapter 531, Government Code, is |
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amended by adding Section 531.1135 to read as follows: |
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Sec. 531.1135. MANAGED CARE ORGANIZATIONS: PROCESS TO |
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RECOUP CERTAIN OVERPAYMENTS. (a) The executive commissioner |
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shall adopt rules that standardize the process by which a managed |
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care organization collects alleged overpayments that are made to a |
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health care provider and discovered through an audit or |
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investigation conducted by the organization secondary to missing |
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electronic visit verification information. In adopting rules under |
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this section, the executive commissioner shall require that the |
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managed care organization: |
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(1) provide written notice of the organization's |
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intent to recoup overpayments not later than the 30th day after the |
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date an audit is complete; and |
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(2) limit the duration of audits to 24 months. |
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(b) The executive commissioner shall require that the |
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notice required under this section inform the provider: |
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(1) of the specific claims and electronic visit |
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verification transactions that are the basis of the overpayment; |
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(2) of the process the provider should use to |
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communicate with the managed care organization to provide |
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information about the electronic visit verification transactions; |
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(3) of the provider's option to seek an informal |
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resolution of the alleged overpayment; |
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(4) of the process to appeal the determination that an |
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overpayment was made; and |
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(5) if the provider intends to respond to the notice, |
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that the provider must respond not later than the 30th day after the |
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date the provider receives the notice. |
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(c) Notwithstanding any other law, a managed care |
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organization may not attempt to recover an overpayment described by |
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Subsection (a) until the provider has exhausted all rights to an |
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appeal. |
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SECTION 4. The Health and Human Services Commission is |
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required to implement a provision of this Act only if the |
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legislature appropriates money to the commission specifically for |
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that purpose. If the legislature does not appropriate money |
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specifically for that purpose, the commission may, but is not |
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required to, implement a provision of this Act using other |
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appropriations that are available for that purpose. |
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SECTION 5. 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 6. This Act takes effect September 1, 2019. |
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