Bill Text: TX SB1483 | 2019-2020 | 86th Legislature | Introduced


Bill Title: Relating to the proof required to impose payment holds in certain cases of alleged fraud by Medicaid providers.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2019-03-14 - Referred to Health & Human Services [SB1483 Detail]

Download: Texas-2019-SB1483-Introduced.html
  86R9790 JG-D
 
  By: Hinojosa S.B. No. 1483
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the proof required to impose payment holds in certain
  cases of alleged fraud by Medicaid providers.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Sections 531.102(g)(2) and (3), Government Code,
  are amended to read as follows:
               (2)  As authorized under state and 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 by the office 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, 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;
                     (B)  a description of administrative and judicial
  due process rights and remedies, including the provider's option 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 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:
                     (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;
                     (B)  the provider and the office are each entitled
  to two continuances under reasonable circumstances; 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 due to:
                           (i)  an ongoing significant financial risk
  to the state that may result in the loss of $100,000 or more; or
                           (ii)  a high probability that a serious
  threat to the health or safety of a recipient exists or may develop
  as a result of the provider's conduct.
         SECTION 2.  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 3.  This Act takes effect immediately if it receives
  a vote of two-thirds of all the members elected to each house, as
  provided by Section 39, Article III, Texas Constitution.  If this
  Act does not receive the vote necessary for immediate effect, this
  Act takes effect September 1, 2019.
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