Source: https://www.gbblegal.com/texas-false-claims-act/
Timestamp: 2019-04-25 19:48:14+00:00

Document:
The Texas Medicaid Fraud Prevention Act allows whistleblowers to bring suit in the name of the State of Texas where a wrongdoer engages in conduct that defrauds the state or local government of its healthcare dollars. This statute is designed to address Medicaid fraud.
(B) not more than $10,000 for each violation that does not result in injury to a person described by Paragraph (A).
(l) If, after informal review, a person who has been ordered to pay a penalty fails to request a formal hearing in a timely manner, the department shall assess the penalty. The department shall give the person written notice of its action. The person shall pay the penalty not later than the 30th day after the date on which the person receives the notice.
(u) A person found liable for a violation under Subsection (c) that resulted in injury to an elderly person, as defined by Section 48.002(1), a disabled person, as defined by Section 48.002(8)(A), or a person younger than 18 years of age may not provide or arrange to provide health care services under the medical assistance program for a period of 10 years. The department by rule may provide for a period of ineligibility longer than 10 years. The period of ineligibility begins on the date on which the determination that the person is liable becomes final. This subsection does not apply to a person who operates a nursing facility or an ICF-MR facility.
(v) A person found liable for a violation under Subsection (c) that did not result in injury to an elderly person, as defined by Section 48.002(1), a disabled person, as defined by Section 48.002(8)(A), or a person younger than 18 years of age may not provide or arrange to provide health care services under the medical assistance program for a period of three years. The department by rule may provide for a period of ineligibility longer than three years. The period of ineligibility begins on the date on which the determination that the person is liable becomes final. This subsection does not apply to a person who operates a nursing facility or an ICF-MR facility.
Added by Acts 1987, 70th Leg., ch. 1052, § 2.04, eff. Sept. 1, 1987.
Amended by Acts 1995, 74th Leg., ch. 76, § 5.95(49), (53), eff. Sept. 1, 1995; Acts 1997, 75th Leg., ch. 1153, § 3.01(a), eff. Sept. 1, 1997; Acts 1999, 76th Leg., ch. 12, §§ 1, 2, eff. Sept. 1, 1999.
(D) a managed care organization.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Amended by Acts 1997, 75th Leg., ch. 1153, § 4.02, eff. Sept. 1, 1997.
(D) obstructs an investigation by the attorney general of an alleged unlawful act under this section.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Amended by Acts 1997, 75th Leg., ch. 1153, § 4.03, eff. Sept. 1, 1997; Acts 1999, 76th Leg., ch. 233, § 4, eff. Sept. 1, 1999.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.007 by Acts 1997, 75th Leg., ch. 1153, § 4.01(a) eff. Sept. 1, 1997.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.008 by Acts 1997, 75th Leg., ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
(B) a permit, license, or certification granted by the department or agency to a person who operates a nursing facility or an ICF-MR facility and who is found liable under Section 36.052.
(b) A person found liable under Section 36.052 for an unlawful act may not provide or arrange to provide health care services under the Medicaid program for a period of 10 years. The board of a state agency that operates part of the Medicaid program may by rule provide for a period of ineligibility longer than 10 years. The period of ineligibility begins on the date on which the determination that the person is liable becomes final. This subsection does not apply to a person who operates a nursing facility or an ICF-MR facility.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.009 by Acts 1997, 75th Leg., ch. 1153, § 4.01(a), eff. Sept. 1, 1997. Amended by Acts 1997, 75th Leg., ch. 1153, § 4.06, eff. Sept. 1, 1997.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.010 by Acts 1997, 75th Leg., ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.011 by Acts 1997, 75th Leg., ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.012 by Acts 1997, 75th Leg., ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.003 by Acts 1997, 75th Leg., ch. 1153, § 4.01(b), eff. Sept. 1, 1997.
Stats. 1995 74th Leg. Sess. Ch. 824, effective September 1, 1995; Stats. 1997 75th Leg. Sess. Chs. 959, 1153, §, Stats. 2001 77th Leg. Sess. Ch. 1481, effective September 1, 2001 (expiration date amended); Stats. 2005 79th Leg. Sess., Ch. 806 (S.B. 563), § 7, effective September 1, 2005; Stats. 2007, 80th Leg. Sess., Ch. 29, § 1, effective May 4, 2007.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.005 by Acts 1997, 75th Leg., ch. 1153, § 4.01(b), eff. Sept. 1, 1997. Amended by Acts 1997, 75th Leg., ch. 1153, § 4.05, eff. Sept. 1, 1997.
(e) Except as ordered by a court for good cause shown, the office of the attorney general may not produce for inspection or copying or otherwise disclose the contents of documentary material obtained under this section to a person other than an authorized employee of the attorney general without the consent of the person who produced the documentary material. The attorney general shall prescribe reasonable terms and conditions allowing the documentary material to be available for inspection and copying by the person who produced the material or by an authorized representative of that person. The attorney general may use the documentary material or copies of it as the attorney general determines necessary in the enforcement of this chapter, including presentation before a court.
Added by Acts 1995, 74th Leg., ch. 824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A., Human Resources Code § 36.006 by Acts 1997, 75th Leg., ch. 1153, § 4.01(b), eff. Sept. 1, 1997.
To the extent permitted by 31 U.S.C. Sections 3729–3733, the attorney general may bring an action as relator under 31 U.S.C. Section 3730 with respect to an act in connection with the Medicaid program for which a person may be held liable under 31 U.S.C. Section 3729. The attorney general may contract with a private attorney to represent the state under this section.
Added by Acts 1997, 75th Leg., ch. 1153, § 4.07(a), eff. Sept. 1, 1997.
Added by Acts 1997, 75th Leg., ch. 1153, § 4.08, eff. Sept. 1, 1997.
(b) The petition shall be filed in camera and shall remain under seal until at least the 60th day after the date the petition is filed. The petition may not be served on the defendant until the court orders service on the defendant.
(c) The state may elect to intervene and proceed with the action not later than the 60th day after the date the attorney general receives the petition and the material evidence and information.
(d) The state may, for good cause shown, move the court to extend the time during which the petition remains under seal under Subsection (b). A motion under this subsection may be supported by affidavits or other submissions in camera.
(e) An action under this subchapter may be dismissed before the end of the period prescribed by Subsection (b), as extended as provided by Subsection (d), if applicable, only if the court and the attorney general consent in writing to the dismissal and state their reasons for consenting.
Added by Stats. 2007, 80th Leg. Sess., Ch. 29, § 2, effective May 4, 2007.
A defendant is not required to file an answer to a petition filed under this subchapter until the 20th day after the date the petition is unsealed and served on the defendant in compliance with the Texas Rules of Civil Procedure.
Stats. 1997 75th Leg. Sess. Ch. 1153, effective September 1, 1997; Stats. 2001 77th Leg. Sess. Ch. 1481, effective September 1, 2001 (expiration date amended); Stats. 2005 79th Leg. Sess., Ch. 806 (S.B. 563), § 12, effective September 1, 2005; Stats. 2007, 80th Leg. Sess., Ch. 29, § 4, effective May 4, 2007.
(c) A payment to a person under this section shall be made from the proceeds of the action. A person receiving a payment under this section is also entitled to receive from the defendant an amount for reasonable expenses, reasonable attorney’s fees, and costs that the court finds to have been necessarily incurred. The court’s determination of expenses, fees, and costs to be awarded under this subsection shall be made only afterthe defendant has been found liable in the action.
Stats. 1997 75th Leg. Sess. Ch. 1153, effective September 1, 1997; Stats. 2001 77th Leg. Sess. Ch. 1481, effective September 1, 2001 (expiration date amended); Stats. 2005 79th Leg. Sess., Ch. 806 (S.B. 563), § 13, effective September 1, 2005; Stats. 2007, 80th Leg. Sess., Ch. 29, § 5, effective May 4, 2007.
(b) A person may not bring an action under this subchapter that is based on the public disclosure of allegations or transactions in a criminal or civil hearing, in a legislative or administrative report, hearing, audit, or investigation, or from the news media, unless the person bringing the action is an original source of the information. In this subsection, “original source” means an individual who has direct and independent knowledge of the information on which the allegations are based and has voluntarily provided the information to the state before filing an action under this subchapter that is based on the information.
(a) A person commits an offense if the person commits an unlawful act under Section 36.002.
(7) a felony of the first degree if the value of any payment or monetary or in-kind benefit provided under the Medicaid program, directly or indirectly, as a result of the unlawful act is $200,000 or more.
(c) If conduct constituting an offense under this section also constitutes an offense under another provision of law, including a provision in the Penal Code, the actor may be prosecuted under either this section or the other provision.
Added by Acts 1997, 75th Leg., ch. 1153, § 4.09, eff. Sept. 1, 1997.
(I) another state agency authorized to regulate a provider who receives or is eligible to receive payment for a health care service under the Medicaid program.
(b) A licensing authority shall revoke a license issued by the authority to a person if the person is convicted of a felony under Section 36.131. In revoking the license, the licensing authority shall comply with all procedures generally applicable to the licensing authority in revoking licenses.
(a) The commission may grant an award to an individual who reports activity that constitutes fraud or abuse of funds in the state Medicaid program or reports overcharges in the program if the commission determines that the disclosure results in the recovery of an overcharge or in the termination of the fraudulent activity or abuse of funds.
(b) The commission shall determine the amount of an award. The award must be equal to not less than 10 percent of the savings to this state that result from the individual’s disclosure. In determining the amount of the award, the commission shall consider how important the disclosure is in ensuring the fiscal integrity of the program.
(c) An award under this section is subject to appropriation. The award must be paid from money appropriated to or otherwise available to the commission, and additional money may not be appropriated to the commission for the purpose of paying the award.
(d) Payment of an award under this section from federal funds is subject to the permissible use under federal law of funds for this purpose.
(e) A person who brings an action under Subchapter C, Chapter 36, Human Resources Code, is not eligible for an award under this section.
Added by Acts 1997, 75th Leg., ch. 165, § 14.16, eff. Sept. 1, 1997; Acts 1997, 75th Leg., ch. 1153, § 1.06(a), eff. Sept. 1, 1997.
(a) The commission, through the commission’s office of investigations and enforcement, is responsible for the investigation of fraud in the provision of health and human services and the enforcement of state law relating to the provision of those services.
(3) maximizing opportunities for referral of cases to the office of the attorney general.
(c) The commission shall train office staff to enable the staff to pursue priority Medicaid and welfare fraud and abuse cases as necessary.
(d) The commission may require employees of health and human services agencies to provide assistance to the commission in connection with the commission’s duties relating to the investigation of fraud in the provision of health and human services.
(e) The commission by rule shall set specific claims criteria that, when met, require the office to begin an investigation.
Added by Acts 1997, 75th Leg., ch. 1153, § 1.06(a), eff. June 20, 1997.
Amended by Acts 1999, 76th Leg., ch. 1289, § 3, eff. Sept. 1, 1999.
(7) the commission and the office of the attorney general to submit information requested by the comptroller about each resolved case for the comptroller’s use in improving fraud detection.
(b) An exchange of information under this section between the office of the attorney general and the commission or a health and human services agency does not affect whether the information is subject to disclosure under Chapter 552.
(c) The commission and the office of the attorney general shall jointly prepare and submit a semiannual report to the governor, lieutenant governor, and speaker of the house of representatives concerning the activities of those agencies in detecting and preventing fraud, waste, and abuse under the state Medicaid program. The report may be consolidated with any other report relating to the same subject matter the commission or office of the attorney general is required to submit under other law.
(d) The commission and the office of the attorney general may not assess or collect investigation and attorney’s fees on behalf of any state agency unless the office of the attorney general or other state agency collects a penalty, restitution, or other reimbursement payment to the state.
(e) The commission shall refer a case of suspected fraud, waste, or abuse under the state Medicaid program to the appropriate district attorney, county attorney, city attorney, or private collection agency if the attorney general fails to act within 30 days of referral of the case to the office of the attorney general. A failure by the attorney general to act within 30 days constitutes approval by the attorney general under Section 2107.003.
(f) The district attorney, county attorney, city attorney, or private collection agency may collect and retain costs associated with the case and 20 percent of the amount of the penalty, restitution, or other reimbursement payment collected.
Added by Acts 1997, 75th Leg., ch. 1153, § 1.06(a), eff. Sept. 1, 1997.
(a) The commission and the attorney general shall execute a memorandum of understanding under which the commission shall provide investigative support as required to the attorney general in connection with cases under Subchapter B, Chapter 36, Human Resources Code. Under the memorandum of understanding, the commission shall assist in performing preliminary investigations and ongoing investigations for actions prosecuted by the attorney general under Subchapter C, Chapter 36, Human Resources Code.
(b) The memorandum of understanding must provide that the commission is not required to provide investigative support in more than 100 open investigations in a fiscal year.
(2) the time by which a referral should be made.
(b) The Texas Department of Health and the Texas Department of Human Services, in cooperation with the commission, shall periodically set a goal of the number of potential cases of fraud, waste, or abuse under the state Medicaid program that each agency will attempt to identify and refer to the commission. The commission shall include information on the agencies’ goals and the success of each agency in meeting the agency’s goal in the report required by Section 531.103(c).
(a) The commission shall use learning or neural network technology to identify and deter fraud in the Medicaid program throughout this state.
(b) The commission shall contract with a private or public entity to develop and implement the technology. The commission may require the entity it contracts with to install and operate the technology at locations specified by the commission, including commission offices.
(c) The data used for neural network processing shall be maintained as an independent subset for security purposes.
(d) The commission shall require each health and human services agency that performs any aspect of the state Medicaid program to participate in the implementation and use of the technology.
(e) The commission shall maintain all information necessary to apply the technology to claims data covering a period of at least two years.
(f) The commission shall refer cases identified by the technology to the commission’s office of investigations and enforcement or the office of the attorney general, as appropriate.
(g) Each month, the learning or neural network technology implemented under this section must match bureau of vital statistics death records with Medicaid claims filed by a provider. If the commission determines that a provider has filed a claim for services provided to a person after the person’s date of death, as determined by the bureau of vital statistics death records, the commission shall refer the case for investigation to the commission’s office of investigations and enforcement.
Amended by Acts 1999, 76th Leg., ch. 215, § 2, eff. Sept. 1, 1999.
(a) The commission shall use an automated fraud investigation tracking system through the commission’s office of investigations and enforcement to monitor the progress of an investigation of suspected fraud, abuse, or insufficient quality of care under the state Medicaid program.
(4) generate standard letters to a provider regarding the status or outcome of an investigation.
(c) The commission shall require each health and human services agency that performs any aspect of the state Medicaid program to participate in the implementation and use of the automated fraud investigation tracking system.
Added by Acts 1999, 76th Leg., ch. 206, § 1, eff. Sept. 1, 1999.
(a) The commission shall use an automated recovery monitoring system to monitor the collections process for a settled case of fraud, abuse, or insufficient quality of care under the state Medicaid program.
(2) provide immediate notice of a provider who has agreed to a monetary payment plan or to deductions through the recoupment program from subsequent Medicaid claims who fails to comply with the settlement agreement, including providing notice of a provider who does not make a scheduled payment or who pays less than the scheduled amount.
(a) The Medicaid and Public Assistance Fraud Oversight Task Force advises and assists the commission and the commission’s office of investigations and enforcement in improving the efficiency of fraud investigations and collections.
(7) Texas Department of Insurance, appointed by the commissioner of insurance.
(c) The comptroller or the comptroller’s designee serves as the presiding officer of the task force. The task force may elect any other necessary officers.
(d) The task force shall meet at least once each fiscal quarter at the call of the presiding officer.
(e) The appointing agency is responsible for the expenses of a member’s service on the task force. Members of the task force receive no additional compensation for serving on the task force.
(2) any additional information the task force requires.
(2) post-fraud referrals received and accepted or rejected from the commission’s case management system or the case management system of a health and human services agency.
(2) ensure that a toll-free hotline for reporting suspected fraud in programs administered by the commission or a health and human services agency is maintained and promoted, either by the commission or by a health and human services agency.
(c) The commission shall develop a cost-effective method of identifying applicants for public assistance in counties bordering other states and in metropolitan areas selected by the commission who are already receiving benefits in other states. If economically feasible, the commission may develop a computerized matching system.
(2) establish a computerized matching system with the Texas Department of Criminal Justice to prevent an incarcerated individual from illegally receiving public assistance benefits administered by the commission.
(e) The commission shall submit to the governor and Legislative Budget Board a semiannual report on the results of computerized matching of commission information with information from neighboring states, if any, and information from the Texas Department of Criminal Justice. The report may be consolidated with any other report relating to the same subject matter the commission is required to submit under other law.

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