84R29844 EES-D
	By: Hinojosa, et al.	S.B. No. 207
	(Gonzales, Raymond)
	Substitute the following for S.B. No. 207:  No.

	A BILL TO BE ENTITLED
	AN ACT
	relating to the authority and duties of the office of inspector
	general of the Health and Human Services Commission.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 531.1011(4), Government Code, is amended
	to read as follows:
	(4)  "Fraud" means an intentional deception or
	misrepresentation made by a person with the knowledge that the
	deception could result in some unauthorized benefit to that person
	or some other person[, including any act that constitutes fraud
	under applicable federal or state law]. The term does not include
	unintentional technical, clerical, or administrative errors.
	SECTION 2.  Section 531.102, Government Code, is amended by
	amending Subsections (g) and (k), amending Subsection (f) as
	amended by S.B. No. 219, Acts of the 84th Legislature, Regular
	Session, 2015, and adding Subsections (a-2), (a-3), (a-4), (a-5),
	(a-6), (f-1), (p), (q), (r), (s), (t), (u), (v), and (w) to read as
	follows:
	(a-2)  Pursuant to federal law, the office shall work in
	consultation with the executive commissioner to adopt rules
	necessary to implement a power or duty of the office related to the
	operations of the office.  Rules adopted under this section may not
	affect Medicaid policies.
	(a-3)  The executive commissioner is responsible for
	performing all administrative support services functions necessary
	to operate the office in the same manner that the executive
	commissioner is responsible for providing administrative support
	services functions for the health and human services system,
	including functions of the office related to the following:
	(1)  procurement processes;
	(2)  contracting policies;
	(3)  information technology services;
	(4)  legal services;
	(5)  budgeting; and
	(6)  personnel and employment policies.
	(a-4)  The commission's internal audit division shall
	regularly audit the office as part of the commission's internal
	audit program and shall include the office in the commission's risk
	assessments.
	(a-5)  The office shall closely coordinate with the
	executive commissioner and the relevant staff of health and human
	services system programs that the office oversees in performing
	functions relating to the prevention of fraud, waste, and abuse in
	the delivery of health and human services and the enforcement of
	state law relating to the provision of those services, including
	audits, utilization reviews, provider education, and data
	analysis.
	(a-6)  The office shall conduct investigations independent
	of the executive commissioner and the commission but shall rely on
	the coordination required by Subsection (a-5) to ensure that the
	office has a thorough understanding of the health and human
	services system for purposes of knowledgeably and effectively
	performing the office's duties under this section and any other
	law.
	(f)(1)  If the commission receives a complaint or allegation
	of Medicaid fraud or abuse from any source, the office must conduct
	a preliminary investigation as provided by Section 531.118(c) to
	determine whether there is a sufficient basis to warrant a full
	investigation.  A preliminary investigation must begin not later
	than the 30th day, and be completed not later than the 45th day,
	after the date the commission receives a complaint or allegation or
	has reason to believe that fraud or abuse has occurred.  [A
	preliminary investigation shall be completed not later than the
	90th day after it began.]
	(2)  If the findings of a preliminary investigation
	give the office reason to believe that an incident of fraud or abuse
	involving possible criminal conduct has occurred in Medicaid, the
	office must take the following action, as appropriate, not later
	than the 30th day after the completion of the preliminary
	investigation:
	(A)  if a provider is suspected of fraud or abuse
	involving criminal conduct, the office must refer the case to the
	state's Medicaid fraud control unit, provided that the criminal
	referral does not preclude the office from continuing its
	investigation of the provider, which investigation may lead to the
	imposition of appropriate administrative or civil sanctions; or
	(B)  if there is reason to believe that a
	recipient has defrauded Medicaid, the office may conduct a full
	investigation of the suspected fraud, subject to Section
	531.118(c).
	(f-1)  The office shall complete a full investigation of a
	complaint or allegation of Medicaid fraud or abuse against a
	provider not later than the 180th day after the date the full
	investigation begins unless the office determines that more time is
	needed to complete the investigation. Except as otherwise provided
	by this subsection, if the office determines that more time is
	needed to complete the investigation, the office shall provide
	notice to the provider who is the subject of the investigation
	stating that the length of the investigation will exceed 180 days
	and specifying the reasons why the office was unable to complete the
	investigation within the 180-day period.  The office is not
	required to provide notice to the provider under this subsection if
	the office determines that providing notice would jeopardize the
	investigation.
	(g)(1)  Whenever the office learns or has reason to suspect
	that a provider's records are being withheld, concealed, destroyed,
	fabricated, or in any way falsified, the office shall immediately
	refer the case to the state's Medicaid fraud control
	unit.  However, such criminal referral does not preclude the office
	from continuing its investigation of the provider, which
	investigation may lead to the imposition of appropriate
	administrative or civil sanctions.
	(2)  As [In addition to other instances] authorized
	under state and [or] 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
	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, [and] 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; [and]
	(B)  a description of administrative and judicial
	due process rights and remedies, including the provider's option
	[right] 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 [30th] 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 [Unless otherwise determined by the administrative law
	judge for good cause at an expedited administrative hearing, the
	state and the provider shall each be responsible for]:
	(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 [one-half of the costs
	charged by the State Office of Administrative Hearings];
	(B)  the provider and the office are each entitled
	to two continuances under reasonable circumstances [one-half of the
	costs for transcribing the hearing]; 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 [the party's own
	costs related to the hearing, including the costs associated with
	preparation for the hearing, discovery, depositions, and
	subpoenas, service of process and witness expenses, travel
	expenses, and investigation expenses; and
	[(D)     all other costs associated with the hearing
	that are incurred by the party, including attorney's fees].
	(4)  Unless otherwise determined by the administrative
	law judge for good cause, the office is responsible for the costs of
	a hearing held under Subdivision (3), but a provider is responsible
	for the provider's own costs incurred in preparing for the hearing
	[The executive commissioner and the State Office of Administrative
	Hearings shall jointly adopt rules that require a provider, before
	an expedited administrative hearing, to advance security for the
	costs for which the provider is responsible under that
	subdivision].
	(5)  In a hearing held under Subdivision (3), the
	administrative law judge shall decide if the payment hold should
	continue but may not adjust the amount or percent of the payment
	hold. Notwithstanding any other law, including Section
	2001.058(e), the decision of the administrative law judge is final
	and may not be appealed [Following an expedited administrative
	hearing under Subdivision (3), a provider subject to a payment
	hold, other than a hold requested by the state's Medicaid fraud
	control unit, may appeal a final administrative order by filing a
	petition for judicial review in a district court in Travis County].
	(6)  The executive commissioner, in consultation with
	the office, shall adopt rules that allow a provider subject to a
	payment hold under Subdivision (2), other than a hold requested by
	the state's Medicaid fraud control unit, to seek an informal
	resolution of the issues identified by the office in the notice
	provided under that subdivision.  A provider must request an
	initial informal resolution meeting under this subdivision not
	later than the deadline prescribed by Subdivision (3) for
	requesting an expedited administrative hearing.  On receipt of a
	timely request, the office shall decide whether to grant the
	provider's request for an initial informal resolution meeting, and
	if the office decides to grant the request, the office shall
	schedule the [an] initial informal resolution meeting [not later
	than the 60th day after the date the office receives the request,
	but the office shall schedule the meeting on a later date, as
	determined by the office, if requested by the provider].  The office
	shall give notice to the provider of the time and place of the
	initial informal resolution meeting [not later than the 30th day
	before the date the meeting is to be held].  A provider may request a
	second informal resolution meeting [not later than the 20th day]
	after the date of the initial informal resolution meeting.  On
	receipt of a timely request, the office shall decide whether to
	grant the provider's request for a second informal resolution
	meeting, and if the office decides to grant the request, the office
	shall schedule the [a] second informal resolution meeting [not
	later than the 45th day after the date the office receives the
	request, but the office shall schedule the meeting on a later date,
	as determined by the office, if requested by the provider].  The
	office shall give notice to the provider of the time and place of
	the second informal resolution meeting [not later than the 20th day
	before the date the meeting is to be held].  A provider must have an
	opportunity to provide additional information before the second
	informal resolution meeting for consideration by the office.  A
	provider's decision to seek an informal resolution under this
	subdivision does not extend the time by which the provider must
	request an expedited administrative hearing under Subdivision (3).
	The informal resolution process shall run concurrently with the
	administrative hearing process, and the informal resolution
	process shall be discontinued once the State Office of
	Administrative Hearings issues a final determination on the payment
	hold. [However, a hearing initiated under Subdivision (3) shall be
	stayed until the informal resolution process is completed.]
	(7)  The office shall, in consultation with the state's
	Medicaid fraud control unit, establish guidelines under which
	[payment holds or] program exclusions:
	(A)  may permissively be imposed on a provider; or
	(B)  shall automatically be imposed on a provider.
	(7-a)  The office shall, in consultation with the
	state's Medicaid fraud control unit, establish guidelines
	regarding the imposition of payment holds authorized under
	Subdivision (2).
	(8)  In accordance with 42 C.F.R. Sections 455.23(e)
	and (f), on the determination that a credible allegation of fraud
	exists, the office may find that good cause exists to not impose a
	payment hold, to not continue a payment hold, to impose a payment
	hold only in part, or to convert a payment hold imposed in whole to
	one imposed only in part, if any of the following are applicable:
	(A)  law enforcement officials have specifically
	requested that a payment hold not be imposed because a payment hold
	would compromise or jeopardize an investigation;
	(B)  available remedies implemented by the state
	other than a payment hold would more effectively or quickly protect
	Medicaid funds;
	(C)  the office determines, based on the
	submission of written evidence by the provider who is the subject of
	the payment hold, that the payment hold should be removed;
	(D)  Medicaid recipients' access to items or
	services would be jeopardized by a full or partial payment hold
	because the provider who is the subject of the payment hold:
	(i)  is the sole community physician or the
	sole source of essential specialized services in a community; or
	(ii)  serves a large number of Medicaid
	recipients within a designated medically underserved area;
	(E)  the attorney general declines to certify that
	a matter continues to be under investigation; or
	(F)  the office determines that a full or partial
	payment hold is not in the best interests of Medicaid.
	(9)  The office may not impose a payment hold on claims
	for reimbursement submitted by a provider for medically necessary
	services for which the provider has obtained prior authorization
	from the commission or a contractor of the commission unless the
	office has evidence that the provider has materially misrepresented
	documentation relating to those services.
	(k)  A final report on an audit or investigation is subject
	to required disclosure under Chapter 552.  All information and
	materials compiled during the audit or investigation remain
	confidential and not subject to required disclosure in accordance
	with Section 531.1021(g). A confidential draft report on an audit
	or investigation that concerns the death of a child may be shared
	with the Department of Family and Protective Services. A draft
	report that is shared with the Department of Family and Protective
	Services remains confidential and is not subject to disclosure
	under Chapter 552.
	(p)  The executive commissioner, in consultation with the
	office, shall adopt rules establishing criteria:
	(1)  for opening a case;
	(2)  for prioritizing cases for the efficient
	management of the office's workload, including rules that direct
	the office to prioritize:
	(A)  provider cases according to the highest
	potential for recovery or risk to the state as indicated through the
	provider's volume of billings, the provider's history of
	noncompliance with the law, and identified fraud trends;
	(B)  recipient cases according to the highest
	potential for recovery and federal timeliness requirements; and
	(C)  internal affairs investigations according to
	the seriousness of the threat to recipient safety and the risk to
	program integrity in terms of the amount or scope of fraud, waste,
	and abuse posed by the allegation that is the subject of the
	investigation; and
	(3)  to guide field investigators in closing a case
	that is not worth pursuing through a full investigation.
	(q)  The executive commissioner, in consultation with the
	office, shall adopt rules establishing criteria for determining
	enforcement and punitive actions with regard to a provider who has
	violated state law, program rules, or the provider's Medicaid
	provider agreement that include:
	(1)  direction for categorizing provider violations
	according to the nature of the violation and for scaling resulting
	enforcement actions, taking into consideration:
	(A)  the seriousness of the violation;
	(B)  the prevalence of errors by the provider;
	(C)  the financial or other harm to the state or
	recipients resulting or potentially resulting from those errors;
	and
	(D)  mitigating factors the office determines
	appropriate; and
	(2)  a specific list of potential penalties, including
	the amount of the penalties, for fraud and other Medicaid
	violations.
	(r)  The office shall review the office's investigative
	process, including the office's use of sampling and extrapolation
	to audit provider records. The review shall be performed by staff
	who are not directly involved in investigations conducted by the
	office.
	(s)  The office shall arrange for the Association of
	Inspectors General or a similar third party to conduct a peer review
	of the office's sampling and extrapolation techniques. Based on
	the review and generally accepted practices among other offices of
	inspectors general, the executive commissioner, in consultation
	with the office, shall by rule adopt sampling and extrapolation
	standards to be used by the office in conducting audits.
	(t)  At each quarterly meeting of any advisory council
	responsible for advising the executive commissioner on the
	operation of the commission, the inspector general shall submit a
	report to the executive commissioner, the governor, and the
	legislature on:
	(1)  the office's activities;
	(2)  the office's performance with respect to
	performance measures established by the executive commissioner for
	the office;
	(3)  fraud trends identified by the office; and
	(4)  any recommendations for changes in policy to
	prevent or address fraud, waste, and abuse in the delivery of health
	and human services in this state.
	(u)  The office shall publish each report required under
	Subsection (t) on the office's Internet website.
	(v)  In accordance with Section 533.015(b), the office shall
	consult with the executive commissioner regarding the adoption of
	rules defining the office's role in and jurisdiction over, and the
	frequency of, audits of managed care organizations participating in
	Medicaid that are conducted by the office and the commission.
	(w)  The office shall coordinate all audit and oversight
	activities relating to providers, including the development of
	audit plans, risk assessments, and findings, with the commission to
	minimize the duplication of activities. In coordinating activities
	under this subsection, the office shall:
	(1)  on an annual basis, seek input from the commission
	and consider previous audits and on-site visits made by the
	commission for purposes of determining whether to audit a managed
	care organization participating in Medicaid; and
	(2)  request the results of any informal audit or
	on-site visit performed by the commission that could inform the
	office's risk assessment when determining whether to conduct, or
	the scope of, an audit of a managed care organization participating
	in Medicaid.
	SECTION 3.  Section 531.1021(a), Government Code, as amended
	by S.B. No. 219, Acts of the 84th Legislature, Regular Session,
	2015, is amended to read as follows:
	(a)  The office of inspector general may issue [request that
	the executive commissioner or the executive commissioner's
	designee approve the issuance by the office of] a subpoena in
	connection with an investigation conducted by the office. A [If the
	request is approved, the office may issue a] subpoena may be issued
	under this section to compel the attendance of a relevant witness or
	the production, for inspection or copying, of relevant evidence
	that is in this state.
	SECTION 4.  Subchapter C, Chapter 531, Government Code, is
	amended by adding Section 531.10225 to read as follows:
	Sec. 531.10225.  ADDITIONAL PEACE OFFICERS. (a) Pursuant
	to federal law, the commission's office of inspector general shall
	employ and commission peace officers for the purpose of assisting
	the office in carrying out, in coordination and conjunction with
	the appropriate federal entities, the duties of the office relating
	to the investigation of fraud, waste, and abuse in the supplemental
	nutrition assistance program under Chapter 33, Human Resources
	Code, and the temporary assistance for needy families program under
	Chapter 31, Human Resources Code.
	(b)  A peace officer employed and commissioned by the office
	under this section is a peace officer for purposes of Article 2.12,
	Code of Criminal Procedure.
	(c)  The office shall supervise a peace officer employed and
	commissioned under this section.
	SECTION 5.  Section 531.1031(a), Government Code, as amended
	by S.B. No. 219, Acts of the 84th Legislature, Regular Session,
	2015, is amended to read as follows:
	(a)  In this section and Sections 531.1032, 531.1033, and
	531.1034:
	(1)  "Health care professional" means a person issued a
	license[, registration, or certification] to engage in a health
	care profession.
	(1-a)  "License" means a license, certificate,
	registration, permit, or other authorization that:
	(A)  is issued by a licensing authority; and
	(B)  must be obtained before a person may practice
	or engage in a particular business, occupation, or profession.
	(1-b)  "Licensing authority" means a department,
	commission, board, office, or other agency of the state that issues
	a license.
	(1-c)  "Office" means the commission's office of
	inspector general unless a different meaning is plainly required by
	the context in which the term appears.
	(2)  "Participating agency" means:
	(A)  the Medicaid fraud enforcement divisions of
	the office of the attorney general;
	(B)  each licensing authority [board or agency]
	with authority to issue a license to[, register, regulate, or
	certify] a health care professional or managed care organization
	that may participate in Medicaid; and
	(C)  the [commission's] office [of inspector
	general].
	(3)  "Provider" has the meaning assigned by Section
	531.1011(10)(A).
	SECTION 6.  Subchapter C, Chapter 531, Government Code, is
	amended by adding Sections 531.1032, 531.1033, and 531.1034 to read
	as follows:
	Sec. 531.1032.  OFFICE OF INSPECTOR GENERAL:  CRIMINAL
	HISTORY RECORD INFORMATION CHECK.  (a)  The office and each
	licensing authority that requires the submission of fingerprints
	for the purpose of conducting a criminal history record information
	check of a health care professional shall enter into a memorandum of
	understanding to ensure that only persons who are licensed and in
	good standing as health care professionals participate as providers
	in Medicaid. The memorandum under this section may be combined with
	a memorandum authorized under Section 531.1031(c-1) and must
	include a process by which:
	(1)  the office may confirm with a licensing authority
	that a health care professional is licensed and in good standing for
	purposes of determining eligibility to participate in Medicaid; and
	(2)  the licensing authority immediately notifies the
	office if:
	(A)  a provider's license has been revoked or
	suspended; or
	(B)  the licensing authority has taken
	disciplinary action against a provider.
	(b)  The office may not, for purposes of determining a health
	care professional's eligibility to participate in Medicaid as a
	provider, conduct a criminal history record information check of a
	health care professional who the office has confirmed under
	Subsection (a) is licensed and in good standing. This subsection
	does not prohibit the office from performing a criminal history
	record information check of a provider that is required or
	appropriate for other reasons, including for conducting an
	investigation of fraud, waste, or abuse.
	(c)  For purposes of determining eligibility to participate
	in Medicaid and subject to Subsection (d), the office, after
	seeking public input, shall establish and the executive
	commissioner by rule shall adopt guidelines for the evaluation of
	criminal history record information of providers and potential
	providers.  The guidelines must outline conduct, by provider type,
	that may be contained in criminal history record information that
	will result in exclusion of a person from Medicaid as a provider,
	taking into consideration:
	(1)  the extent to which the underlying conduct relates
	to the services provided under Medicaid;
	(2)  the degree to which the person would interact with
	Medicaid recipients as a provider; and
	(3)  any previous evidence that the person engaged in
	fraud, waste, or abuse under Medicaid.
	(d)  The guidelines adopted under Subsection (c) may not
	impose stricter standards for the eligibility of a person to
	participate in Medicaid than a licensing authority described by
	Subsection (a) requires for the person to engage in a health care
	profession without restriction in this state.
	(e)  The office and the commission shall use the guidelines
	adopted under Subsection (c) to determine whether a provider
	participating in Medicaid continues to be eligible to participate
	in Medicaid as a provider.
	(f)  The provider enrollment contractor, if applicable, and
	a managed care organization participating in Medicaid shall defer
	to the office regarding whether a person's criminal history record
	information precludes the person from participating in Medicaid as
	a provider.
	Sec. 531.1033.  MONITORING OF CERTAIN FEDERAL DATABASES.
	The office shall routinely check appropriate federal databases,
	including databases referenced in 42 C.F.R. Section 455.436, to
	ensure that a person who is excluded from participating in Medicaid
	or in the Medicare program by the federal government is not
	participating as a provider in Medicaid.
	Sec. 531.1034.  TIME TO DETERMINE PROVIDER ELIGIBILITY;
	PERFORMANCE METRICS.  (a)  Not later than the 10th day after the
	date the office receives the complete application of a health care
	professional seeking to participate in Medicaid, the office shall
	inform the commission or the health care professional, as
	appropriate, of the office's determination regarding whether the
	health care professional should be denied participation in Medicaid
	based on:
	(1)  information concerning the licensing status of the
	health care professional obtained as described by Section
	531.1032(a);
	(2)  information contained in the criminal history
	record information check that is evaluated in accordance with
	guidelines adopted under Section 531.1032(c);
	(3)  a review of federal databases under Section
	531.1033;
	(4)  the pendency of an open investigation by the
	office; or
	(5)  any other reason the office determines
	appropriate.
	(b)  Completion of an on-site visit of a health care
	professional during the period prescribed by Subsection (a) is not
	required.
	(c)  The office shall develop performance metrics to measure
	the length of time for conducting a determination described by
	Subsection (a) with respect to applications that are complete when
	submitted and all other applications.
	SECTION 7.  Section 531.113, Government Code, is amended by
	adding Subsection (d-1) and amending Subsection (e) as amended by
	S.B. No. 219, Acts of the 84th Legislature, Regular Session, 2015,
	to read as follows:
	(d-1)  The commission's office of inspector general, in
	consultation with the commission, shall:
	(1)  investigate, including by means of regular audits,
	possible fraud, waste, and abuse by managed care organizations
	subject to this section;
	(2)  establish requirements for the provision of
	training to and regular oversight of special investigative units
	established by managed care organizations under Subsection (a)(1)
	and entities with which managed care organizations contract under
	Subsection (a)(2);
	(3)  establish requirements for approving plans to
	prevent and reduce fraud and abuse adopted by managed care
	organizations under Subsection (b);
	(4)  evaluate statewide fraud, waste, and abuse trends
	in Medicaid and communicate those trends to special investigative
	units and contracted entities to determine the prevalence of those
	trends;
	(5)  assist managed care organizations in discovering
	or investigating fraud, waste, and abuse, as needed; and
	(6)  provide ongoing, regular training to appropriate
	commission and office staff concerning fraud, waste, and abuse in a
	managed care setting, including training relating to fraud, waste,
	and abuse by service providers and recipients.
	(e)  The executive commissioner, in consultation with the
	office, shall adopt rules as necessary to accomplish the purposes
	of this section, including rules defining the investigative role of
	the commission's office of inspector general with respect to the
	investigative role of special investigative units established by
	managed care organizations under Subsection (a)(1) and entities
	with which managed care organizations contract under Subsection
	(a)(2). The rules adopted under this section must specify the
	office's role in:
	(1)  reviewing the findings of special investigative
	units and contracted entities;
	(2)  investigating cases in which the overpayment
	amount sought to be recovered exceeds $100,000; and
	(3)  investigating providers who are enrolled in more
	than one managed care organization.
	SECTION 8.  Section 531.118(b), Government Code, is amended
	to read as follows:
	(b)  If the commission receives an allegation of fraud or
	abuse against a provider from any source, the commission's office
	of inspector general shall conduct a preliminary investigation of
	the allegation to determine whether there is a sufficient basis to
	warrant a full investigation.  A preliminary investigation must
	begin not later than the 30th day, and be completed not later than
	the 45th day, after the date the commission receives or identifies
	an allegation of fraud or abuse.
	SECTION 9.  Section 531.120, Government Code, is amended to
	read as follows:
	Sec. 531.120.  NOTICE AND INFORMAL RESOLUTION OF PROPOSED
	RECOUPMENT OF OVERPAYMENT OR DEBT. (a) The commission or the
	commission's office of inspector general shall provide a provider
	with written notice of any proposed recoupment of an overpayment or
	debt and any damages or penalties relating to a proposed recoupment
	of an overpayment or debt arising out of a fraud or abuse
	investigation.  The notice must include:
	(1)  the specific basis for the overpayment or debt;
	(2)  a description of facts and supporting evidence;
	(3)  a representative sample of any documents that form
	the basis for the overpayment or debt;
	(4)  the extrapolation methodology;
	(4-a)  information relating to the extrapolation
	methodology used as part of the investigation and the methods used
	to determine the overpayment or debt in sufficient detail so that
	the extrapolation results may be demonstrated to be statistically
	valid and are fully reproducible;
	(5)  the calculation of the overpayment or debt amount;
	(6)  the amount of damages and penalties, if
	applicable; and
	(7)  a description of administrative and judicial due
	process remedies, including the provider's option [right] to seek
	informal resolution, the provider's right to seek a formal
	administrative appeal hearing, or that the provider may seek both.
	(b)  A provider may [must] request an [initial] informal
	resolution meeting under this section, and on [not later than the
	30th day after the date the provider receives notice under
	Subsection (a).   On] receipt of the [a timely] request, the office
	shall schedule the [an initial] informal resolution meeting [not
	later than the 60th day after the date the office receives the
	request, but the office shall schedule the meeting on a later date,
	as determined by the office if requested by the provider].  The
	office shall give notice to the provider of the time and place of
	the [initial] informal resolution meeting [not later than the 30th
	day before the date the meeting is to be held].  The informal
	resolution process shall run concurrently with the administrative
	hearing process, and the administrative hearing process may not be
	delayed on account of the informal resolution process.  [A provider
	may request a second informal resolution meeting not later than the
	20th day after the date of the initial informal resolution meeting.
	On receipt of a timely request, the office shall schedule a second
	informal resolution meeting not later than the 45th day after the
	date the office receives the request, but the office shall schedule
	the meeting on a later date, as determined by the office if
	requested by the provider.   The office shall give notice to the
	provider of the time and place of the second informal resolution
	meeting not later than the 20th day before the date the meeting is
	to be held.   A provider must have an opportunity to provide
	additional information before the second informal resolution
	meeting for consideration by the office.]
	SECTION 10.  Sections 531.1201(a) and (b), Government Code,
	are amended to read as follows:
	(a)  A provider must request an appeal under this section not
	later than the 30th [15th] day after the date the provider is
	notified that the commission or the commission's office of
	inspector general will seek to recover an overpayment or debt from
	the provider.  On receipt of a timely written request by a provider
	who is the subject of a recoupment of overpayment or recoupment of
	debt arising out of a fraud or abuse investigation, the office of
	inspector general shall file a docketing request with the State
	Office of Administrative Hearings or the Health and Human Services
	Commission appeals division, as requested by the provider, for an
	administrative hearing regarding the proposed recoupment amount
	and any associated damages or penalties.  The office shall file the
	docketing request under this section not later than the 60th day
	after the date of the provider's request for an administrative
	hearing or not later than the 60th day after the completion of the
	informal resolution process, if applicable.
	(b)  Unless otherwise determined by the administrative law
	judge for good cause, the commission's office of inspector general
	is responsible for the costs of an administrative hearing held
	under Subsection (a), but a provider is responsible for the
	provider's own costs incurred in preparing for the hearing [at any
	administrative hearing under this section before the State Office
	of Administrative Hearings, the state and the provider shall each
	be responsible for:
	[(1)     one-half of the costs charged by the State Office
	of Administrative Hearings;
	[(2)     one-half of the costs for transcribing the
	hearing;
	[(3)     the party's own costs related to the hearing,
	including the costs associated with preparation for the hearing,
	discovery, depositions, and subpoenas, service of process and
	witness expenses, travel expenses, and investigation expenses; and
	[(4)     all other costs associated with the hearing that
	are incurred by the party, including attorney's fees].
	SECTION 11.  Section 531.1202, Government Code, is amended
	to read as follows:
	Sec. 531.1202.  RECORD AND CONFIDENTIALITY OF INFORMAL
	RESOLUTION MEETINGS.  (a)  On the written request of the provider,
	the [The] commission shall, at no expense to the provider who
	requested the meeting, provide for an informal resolution meeting
	held under Section 531.102(g)(6) or 531.120(b) to be recorded.  The
	recording of an informal resolution meeting shall be made available
	to the provider who requested the meeting. The commission may not
	record an informal resolution meeting unless the commission
	receives a written request from a provider under this subsection.
	(b)  Notwithstanding Section 531.1021(g) and except as
	provided by this section, an informal resolution meeting held under
	Section 531.102(g)(6) or 531.120(b) is confidential, and any
	information or materials obtained by the commission's office of
	inspector general, including the office's employees or the office's
	agents, during or in connection with an informal resolution
	meeting, including a recording made under Subsection (a), are
	privileged and confidential and not subject to disclosure under
	Chapter 552 or any other means of legal compulsion for release,
	including disclosure, discovery, or subpoena.
	SECTION 12.  Subchapter C, Chapter 531, Government Code, is
	amended by adding Sections 531.1023, 531.1024, 531.1025, and
	531.1203 to read as follows:
	Sec. 531.1023.  COMPLIANCE WITH FEDERAL CODING GUIDELINES.
	The commission's office of inspector general, including office
	staff and any third party with which the office contracts to perform
	coding services, shall comply with federal coding guidelines,
	including guidelines for diagnosis-related group (DRG) validation
	and related audits.
	Sec. 531.1024.  HOSPITAL UTILIZATION REVIEWS AND AUDITS:
	PROVIDER EDUCATION PROCESS.  The executive commissioner, in
	consultation with the office, shall by rule develop a process for
	the commission's office of inspector general, including office
	staff and any third party with which the office contracts to perform
	coding services, to communicate with and educate providers about
	the diagnosis-related group (DRG) validation criteria that the
	office uses in conducting hospital utilization reviews and audits.
	Sec. 531.1025.  PERFORMANCE AUDITS AND COORDINATION OF AUDIT
	ACTIVITIES. (a)  Notwithstanding any other law, the commission's
	office of inspector general may conduct a performance audit of any
	program or project administered or agreement entered into by the
	commission or a health and human services agency, including an
	audit related to:
	(1)  contracting procedures of the commission or a
	health and human services agency; or
	(2)  the performance of the commission or a health and
	human services agency.
	(b)  In addition to the coordination required by Section
	531.102(w), the office shall coordinate the office's other audit
	activities with those of the commission, including the development
	of audit plans, the performance of risk assessments, and the
	reporting of findings, to minimize the duplication of audit
	activities. In coordinating audit activities with the commission
	under this subsection, the office shall:
	(1)  seek input from the commission and consider
	previous audits conducted by the commission for purposes of
	determining whether to conduct a performance audit; and
	(2)  request the results of an audit conducted by the
	commission if those results could inform the office's risk
	assessment when determining whether to conduct, or the scope of, a
	performance audit.
	Sec. 531.1203.  RIGHTS OF AND PROVISION OF INFORMATION TO
	PHARMACIES SUBJECT TO CERTAIN AUDITS. (a)  A pharmacy has a right
	to request an informal hearing before the commission's appeals
	division to contest the findings of an audit conducted by the
	commission's office of inspector general or an entity that
	contracts with the federal government to audit Medicaid providers
	if the findings of the audit do not include findings that the
	pharmacy engaged in Medicaid fraud.
	(b)  In an informal hearing held under this section, staff of
	the commission's appeals division, assisted by staff responsible
	for the commission's vendor drug program who have expertise in the
	law governing pharmacies' participation in Medicaid, make the final
	decision on whether the findings of an audit are accurate.  Staff of
	the commission's office of inspector general may not serve on the
	panel that makes the decision on the accuracy of an audit.
	(c)  In order to increase transparency, the commission's
	office of inspector general shall, if the office has access to the
	information, provide to pharmacies that are subject to audit by the
	office, or by an entity that contracts with the federal government
	to audit Medicaid providers, information relating to the
	extrapolation methodology used as part of the audit and the methods
	used to determine whether the pharmacy has been overpaid under
	Medicaid in sufficient detail so that the audit results may be
	demonstrated to be statistically valid and are fully reproducible.
	SECTION 13.  Section 533.015, Government Code, as amended by
	S.B. No. 219, Acts of the 84th Legislature, Regular Session, 2015,
	is amended to read as follows:
	Sec. 533.015.  COORDINATION OF EXTERNAL OVERSIGHT
	ACTIVITIES. (a)  To the extent possible, the commission shall
	coordinate all external oversight activities to minimize
	duplication of oversight of managed care plans under Medicaid and
	disruption of operations under those plans.
	(b)  The executive commissioner, after consulting with the
	commission's office of inspector general, shall by rule define the
	commission's and office's roles in and jurisdiction over, and
	frequency of, audits of managed care organizations participating in
	Medicaid that are conducted by the commission and the commission's
	office of inspector general.
	(c)  In accordance with Section 531.102(w), the commission
	shall share with the commission's office of inspector general, at
	the request of the office, the results of any informal audit or
	on-site visit that could inform that office's risk assessment when
	determining whether to conduct, or the scope of, an audit of a
	managed care organization participating in Medicaid.
	SECTION 14.  The following provisions are repealed:
	(1)  Section 531.1201(c), Government Code; and
	(2)  Section 32.0422(k), Human Resources Code, as
	amended by S.B. No. 219, Acts of the 84th Legislature, Regular
	Session, 2015.
	SECTION 15.  Notwithstanding Section 531.004, Government
	Code, the Sunset Advisory Commission shall conduct a
	special-purpose review of the overall performance of the Health and
	Human Services Commission's office of inspector general.  In
	conducting the review, the Sunset Advisory Commission shall
	particularly focus on the office's investigations and the
	effectiveness and efficiency of the office's processes, as part of
	the Sunset Advisory Commission's review of agencies for the 87th
	Legislature.  The office is not abolished solely because the office
	is not explicitly continued following the review.
	SECTION 16.  Section 531.102, Government Code, as amended by
	this Act, applies only to a complaint or allegation of Medicaid
	fraud or abuse received by the Health and Human Services Commission
	or the commission's office of inspector general on or after the
	effective date of this Act. A complaint or allegation received
	before the effective date of this Act is governed by the law as it
	existed when the complaint or allegation was received, and the
	former law is continued in effect for that purpose.
	SECTION 17.  Not later than March 1, 2016, the executive
	commissioner of the Health and Human Services Commission, in
	consultation with the inspector general of the commission's office
	of inspector general, shall adopt rules necessary to implement the
	changes in law made by this Act to Section 531.102(g)(2),
	Government Code, regarding the circumstances in which a payment
	hold may be placed on claims for reimbursement submitted by a
	Medicaid provider.
	SECTION 18.  As soon as practicable after the effective date
	of this Act, the executive commissioner of the Health and Human
	Services Commission, in consultation with the inspector general of
	the commission's office of inspector general, shall adopt the rules
	establishing the process for communicating with and educating
	providers about diagnosis-related group (DRG) validation criteria
	under Section 531.1024, Government Code, as added by this Act.
	SECTION 19.  Not later than September 1, 2016, the executive
	commissioner of the Health and Human Services Commission shall
	adopt the guidelines required under Section 531.1032(c),
	Government Code, as added by this Act.
	SECTION 20.  Sections 531.120 and 531.1201, Government Code,
	as amended by this Act, apply only to a proposed recoupment of an
	overpayment or debt of which a provider is notified on or after the
	effective date of this Act. A proposed recoupment of an overpayment
	or debt that a provider was notified of before the effective date of
	this Act is governed by the law as it existed when the provider was
	notified, and the former law is continued in effect for that
	purpose.
	SECTION 21. (a) Not later than March 1, 2016, the executive
	commissioner of the Health and Human Services Commission, in
	consultation with the inspector general of the commission's office
	of inspector general, shall adopt rules necessary to implement
	Section 531.1203, Government Code, as added by this Act.
	(b)  Section 531.1203, Government Code, as added by this Act,
	applies to:
	(1)  the findings of an audit that are made on or after
	the effective date of this Act; or
	(2)  an audit the results of which are the subject of a
	dispute pending on the effective date of this Act.
	SECTION 22.  Not later than September 1, 2016, the executive
	commissioner of the Health and Human Services Commission shall
	adopt rules required by Section 533.015(b), Government Code, as
	added by this Act.
	SECTION 23.  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 24.  This Act takes effect September 1, 2015.