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A BILL TO BE ENTITLED
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AN ACT
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relating to the review of claims and recovery of overpayments by |
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Medicaid recovery audit contractors. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 544.0504, Government Code, is amended to |
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read as follows: |
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Sec. 544.0504. RECOVERY AUDIT CONTRACTORS. (a) To the |
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extent required under Section 1902(a)(42), Social Security Act (42 |
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U.S.C. Section 1396a(a)(42)), the commission shall establish a |
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program under which the commission contracts with one or more |
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recovery audit contractors to: |
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(1) identify Medicaid underpayments and overpayments, |
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including underpayments and overpayments under the Medicaid |
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managed care program; and |
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(2) recover the overpayments. |
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(b) An overpayment under Subsection (a)(2) may be recovered |
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from either the provider or the managed care organization. |
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(c) A recovery audit contractor may not: |
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(1) initiate a review of a claim unless: |
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(A) the office of inspector general or the |
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office's designee: |
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(i) determines that the review would be |
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cost-effective; and |
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(ii) approves the review; and |
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(B) at least one year has elapsed since the date |
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the claim was received; or |
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(2) initiate a recovery effort on a claim if a managed |
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care organization has notified the office of inspector general that |
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the organization is auditing the claim. |
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(d) On request by a recovery audit contractor or the office |
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of inspector general, a managed care organization or provider who |
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is the subject of a review conducted under this section shall submit |
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to the contractor or office all information necessary to perform |
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the review not later than the date specified in the request. All |
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information and materials obtained under this section are |
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confidential under Section 544.0259(e). |
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(e) The executive commissioner by rule shall adopt a process |
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for appeals related to overpayments identified by a recovery audit |
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contractor under this section. |
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(f) The commission may contract with a third party to |
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administer Subsection (b) or the appeals process adopted under |
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Subsection (e). |
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(g) The executive commissioner, in consultation with the |
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office of inspector general, may adopt rules necessary to implement |
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this section. |
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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. The Health and Human Services Commission is |
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required to implement the changes in law made by this Act to Section |
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544.0504, Government Code, only if the legislature appropriates |
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money specifically for that purpose. If the legislature does not |
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appropriate money specifically for that purpose, the commission |
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may, but is not required to, implement those changes in law using |
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other money available to the commission for that purpose. |
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SECTION 4. This Act takes effect September 1, 2025. |