reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0110. Reports on Audits, Inspections, and Investigations

Text of section effective on April 01, 2025
Sec. 544.0110.  REPORTS ON AUDITS, INSPECTIONS, AND INVESTIGATIONS.  (a)  The office of inspector general shall prepare a final report on each audit, inspection, or investigation conducted under Section 544.0102, 544.0103, 544.0252(b), 544.0254, or 544.0257.  The final report must include:
(1)  a summary of the activities the office performed in conducting the audit, inspection, or investigation;
(2)  a statement on whether the audit, inspection, or investigation resulted in a finding of any wrongdoing; and
(3)  a description of any findings of wrongdoing.
(b)  A final report on an audit, inspection, or investigation is subject to required disclosure under Chapter 552.  All information and materials compiled during the audit, inspection, or investigation remain confidential and not subject to required disclosure in accordance with Section 544.0259(e).
(c)  A confidential draft report on an audit, inspection, 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.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0111. Compliance With Federal Coding Guidelines

Text of section effective on April 01, 2025
Sec. 544.0111.  COMPLIANCE WITH FEDERAL CODING GUIDELINES.  (a)  In this section, "federal coding guidelines" means the code sets and guidelines the United States Department of Health and Human Services adopts in accordance with the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.).
(b)  The office of inspector general, including office staff and any third party with which the office contracts to perform coding services, and the commission's medical and utilization review appeals unit shall comply with federal coding guidelines, including guidelines for diagnosis-related group (DRG) validation and related audits.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0112. Hospital Utilization Reviews and Audits: Provider Education Process

Text of section effective on April 01, 2025
Sec. 544.0112.  HOSPITAL UTILIZATION REVIEWS AND AUDITS: PROVIDER EDUCATION PROCESS. The executive commissioner, in consultation with the office of inspector general, shall develop by rule a process for the office, 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.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0113. Program Exclusions

Text of section effective on April 01, 2025
Sec. 544.0113.  PROGRAM EXCLUSIONS.  The office of inspector general, in consultation with this state's Medicaid fraud control unit, shall establish guidelines under which program exclusions:
(1)  may permissively be imposed on a provider; or
(2)  shall automatically be imposed on a provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0114. Report

Text of section effective on April 01, 2025
Sec. 544.0114.  REPORT.  (a)  At each quarterly meeting of any advisory council responsible for advising the executive commissioner on the commission's operation, the inspector general shall submit to the executive commissioner, the governor, and the legislature a report on:
(1)  the office of inspector general's activities;
(2)  the office's performance with respect to performance measures the executive commissioner establishes for the office;
(3)  fraud trends the office has identified;
(4)  any recommendations for policy changes to prevent or address fraud, waste, and abuse in the delivery of health and human services in this state; and
(5)  the amount of money recovered during the preceding quarter as a result of investigations involving peace officers employed and commissioned by the office for each program for which the office has investigative authority.
(b)  The office of inspector general shall publish each report required under this section on the office's Internet website.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter D. Medicaid Provider Criminal History Record Information and Eligibility › Section 544.0151. Definitions

Text of section effective on April 01, 2025
Sec. 544.0151.  DEFINITIONS.  In this subchapter:
(1)  "Health care professional" means an individual issued a license to engage in a health care profession.
(2)  "License" means a license, certificate, registration, permit, or other authorization that:
(A)  a licensing authority issues; and
(B)  must be obtained before a person may practice or engage in a particular business, occupation, or profession.
(3)  "Licensing authority" means a department, commission, board, office, or other state agency that issues a license.
(4)  "Participating agency" means:
(A)  the Medicaid fraud enforcement divisions of the office of the attorney general;
(B)  each licensing authority with authority to issue a license to a health care professional or managed care organization that may participate in Medicaid; and
(C)  the office of inspector general.
(5)  "Provider" means a person that was or is approved by the commission to provide Medicaid services under a contract or provider agreement with the commission.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter D. Medicaid Provider Criminal History Record Information and Eligibility › Section 544.0154. Monitoring of Certain Federal Databases

Text of section effective on April 01, 2025
Sec. 544.0154.  MONITORING OF CERTAIN FEDERAL DATABASES.  The office of inspector general shall routinely check appropriate federal databases, including databases referenced in 42 C.F.R. Section 455.436, to ensure that a person excluded by the federal government from participating in Medicaid or Medicare is not participating as a Medicaid provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter D. Medicaid Provider Criminal History Record Information and Eligibility › Section 544.0155. Period for Determining Provider Eligibility for Medicaid

Text of section effective on April 01, 2025
Sec. 544.0155.  PERIOD FOR DETERMINING PROVIDER ELIGIBILITY FOR MEDICAID.  (a)  Not later than the 10th day after the date the office of inspector general receives a health care professional's complete application seeking to participate in Medicaid, the office shall inform the commission or the health care professional, as appropriate, of the office's determination of whether the health care professional should be denied participation in Medicaid based on:
(1)  information concerning the health care professional's licensing status obtained as described by Section 544.0153(a);
(2)  information contained in the criminal history record information check that is evaluated in accordance with guidelines the executive commissioner adopts under Section 544.0153(c);
(3)  a review of federal databases under Section 544.0154;
(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 of inspector general shall develop performance metrics to measure the length of time for conducting a determination described by Subsection (a) with respect to:
(1)  applications that are complete when submitted; and
(2)  all other applications.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter E. Prevention and Detection of Fraud, Waste, and Abuse › Section 544.0201. Selection and Review of Medicaid Claims to Determine Resource Allocation

Text of section effective on April 01, 2025
Sec. 544.0201.  SELECTION AND REVIEW OF MEDICAID CLAIMS TO DETERMINE RESOURCE ALLOCATION.  (a)  The commission shall annually select and review a random, statistically valid sample of all claims for Medicaid reimbursement, including under the vendor drug program, for potential cases of fraud, waste, or abuse.
(b)  In conducting the annual review of claims, the commission may directly contact a recipient by telephone, in person, or both to verify that the services for which a provider submitted a reimbursement claim were actually provided to the recipient.
(c)  Based on the results of the annual review of claims, the commission shall determine the types of claims toward which commission resources for fraud and abuse detection should be primarily directed.
(d)  Absent an allegation of fraud, waste, or abuse, the commission may conduct an annual review of claims only after the commission completes the prior year's annual review of claims.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter E. Prevention and Detection of Fraud, Waste, and Abuse › Section 544.0202. Duties Related to Fraud Prevention

Text of section effective on April 01, 2025
Sec. 544.0202.  DUTIES RELATED TO FRAUD PREVENTION.  (a)  The office of inspector general shall compile and disseminate accurate information and statistics relating to:
(1)  fraud prevention; and
(2)  post-fraud referrals received and accepted or rejected from the commission's or a health and human services agency's case management system.
(b)  The commission shall:
(1)  aggressively publicize successful fraud prosecutions and fraud-prevention programs through all available means, including the use of statewide press releases; and
(2)  ensure that the commission or a health and human services agency maintains and promotes a toll-free telephone hotline for reporting suspected fraud in programs the commission or a health and human services agency administers.
(c)  The commission shall develop a cost-effective method to identify applicants for public assistance in counties bordering other states and in metropolitan areas the commission selects who are already receiving benefits in other states.  If economically feasible, the commission may develop a computerized matching system.
(d)  The commission shall:
(1)  verify automobile information that is used as eligibility criteria; and
(2)  establish with the Texas Department of Criminal Justice a computerized matching system to prevent an incarcerated individual from illegally receiving public assistance benefits the commission administers.
(e)  Not later than October 1 of each year, the commission shall submit to the governor and Legislative Budget Board a 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 commission may consolidate the report with any other report relating to the same subject matter the commission is required to submit under other law.
(f)  The commission and each health and human services agency that administers part of Medicaid shall maintain statistics on the number, type, and disposition of fraudulent benefits claims submitted under the part of the program the agency administers.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter E. Prevention and Detection of Fraud, Waste, and Abuse › Section 544.0203. Fraud, Waste, and Abuse Detection Training

Text of section effective on April 01, 2025
Sec. 544.0203.  FRAUD, WASTE, AND ABUSE DETECTION TRAINING.  (a)  The commission shall develop and implement a program to provide annual training on identifying potential cases of Medicaid fraud, waste, or abuse to:
(1)  contractors who process Medicaid claims; and
(2)  appropriate health and human services agency staff.
(b)  The training must include clear criteria that specify:
(1)  the circumstances under which a person should refer a potential case to the commission; and
(2)  the time by which a referral should be made.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter E. Prevention and Detection of Fraud, Waste, and Abuse › Section 544.0204. Health and Human Services Agency Medicaid Fraud, Waste, and Abuse Detection Goal

Text of section effective on April 01, 2025
Sec. 544.0204.  HEALTH AND HUMAN SERVICES AGENCY MEDICAID FRAUD, WASTE, AND ABUSE DETECTION GOAL.  (a)  The health and human services agencies, in cooperation with the commission, shall periodically set a goal for the number of potential cases of Medicaid fraud, waste, or abuse that each agency will attempt to identify and refer to the commission.
(b)  The commission shall include in the report required by Section 544.0051(f) information on the health and human services agencies' goals and the success of each agency in meeting the agency's goal.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter E. Prevention and Detection of Fraud, Waste, and Abuse › Section 544.0205. Award for Reporting Medicaid Fraud, Abuse, or Overcharges

Text of section effective on April 01, 2025
Sec. 544.0205.  AWARD FOR REPORTING MEDICAID FRAUD, ABUSE, OR OVERCHARGES.  (a)  The commission may grant an award to an individual who reports activity that constitutes fraud or abuse of Medicaid funds or who reports Medicaid overcharges if the commission determines that the disclosure results in the recovery of an administrative penalty imposed under Section 32.039, Human Resources Code.  The commission may not grant an award to an individual in connection with a report if the commission or attorney general had independent knowledge of the activity the individual reported.
(b)  The commission shall determine the amount of an award.  The award may not exceed five percent of the amount of the administrative penalty imposed under Section 32.039, Human Resources Code, that resulted from the individual's disclosure.  In determining the award amount, the commission:
(1)  shall consider how important the disclosure is in ensuring the fiscal integrity of Medicaid; and
(2)  may consider whether the individual participated in the fraud, abuse, or overcharge.
(c)  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 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0251. Claims Criteria Requiring Commencement of Investigation

Text of section effective on April 01, 2025
Sec. 544.0251.  CLAIMS CRITERIA REQUIRING COMMENCEMENT OF INVESTIGATION.  The executive commissioner, in consultation with the inspector general, by rule shall set specific claims criteria that, when met, require the office of inspector general to begin an investigation.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0252. Circumstances Requiring Commencement of Preliminary Investigation of Alleged Fraud or Abuse

Text of section effective on April 01, 2025
Sec. 544.0252.  CIRCUMSTANCES REQUIRING COMMENCEMENT OF PRELIMINARY INVESTIGATION OF ALLEGED FRAUD OR ABUSE.  (a)  The office of inspector general shall conduct a preliminary investigation of an allegation of fraud or abuse against a provider that the commission receives from any source to determine whether there is a sufficient basis to warrant a full investigation.  The office must begin a preliminary investigation not later than the 30th day and complete the preliminary investigation not later than the 45th day after the date the commission receives or identifies an allegation of fraud or abuse.
(b)  The office of inspector general shall conduct a preliminary investigation as provided by Section 544.0253 of a complaint or allegation of Medicaid fraud or abuse that the commission receives from any source to determine whether there is a sufficient basis to warrant a full investigation.  The office must begin a preliminary investigation not later than the 30th day and complete the preliminary investigation 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.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0253. Conduct of Preliminary Investigation of Alleged Fraud or Abuse

Text of section effective on April 01, 2025
Sec. 544.0253.  CONDUCT OF PRELIMINARY INVESTIGATION OF ALLEGED FRAUD OR ABUSE.  In conducting a preliminary investigation of an allegation of fraud or abuse and before the allegation may proceed to a full investigation, the office of inspector general must:
(1)  review the allegation and all facts and evidence relating to the allegation; and
(2)  prepare a preliminary investigation report that documents:
(A)  the allegation;
(B)  the evidence the office reviewed, if available;
(C)  the procedures the office used to conduct the preliminary investigation;
(D)  the preliminary investigation findings; and
(E)  the office's determination of whether a full investigation is warranted.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0254. Finding of Certain Medicaid Fraud or Abuse Following Preliminary Investigation: Criminal Referral or Full Investigation

Text of section effective on April 01, 2025
Sec. 544.0254.  FINDING OF CERTAIN MEDICAID FRAUD OR ABUSE FOLLOWING PRELIMINARY INVESTIGATION: CRIMINAL REFERRAL OR FULL INVESTIGATION.  If the findings of a preliminary investigation give the office of inspector general reason to believe that an incident of Medicaid fraud or abuse involving possible criminal conduct has occurred, not later than the 30th day after completing the preliminary investigation, the office, as appropriate:
(1)  must refer the case to this state's Medicaid fraud control unit if a provider is suspected of fraud or abuse involving criminal conduct, provided that the criminal referral does not preclude the office from continuing the office's investigation of the provider that may lead to the imposition of appropriate administrative or civil sanctions; or
(2)  may conduct a full investigation, subject to Section 544.0253, if there is reason to believe that a recipient has defrauded Medicaid.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0255. Immediate Criminal Referral Under Certain Circumstances

Text of section effective on April 01, 2025
Sec. 544.0255.  IMMEDIATE CRIMINAL REFERRAL UNDER CERTAIN CIRCUMSTANCES.  If the office of inspector general 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 this state's Medicaid fraud control unit.  The criminal referral does not preclude the office from continuing the office's investigation of the provider that may lead to the imposition of appropriate administrative or civil sanctions.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0256. Continuation of Payment Hold Following Referral to Law Enforcement Agency

Text of section effective on April 01, 2025
Sec. 544.0256.  CONTINUATION OF PAYMENT HOLD FOLLOWING REFERRAL TO LAW ENFORCEMENT AGENCY.  (a)  If this state's Medicaid fraud control unit or another law enforcement agency accepts a fraud referral from the office of inspector general for investigation, a payment hold based on a credible allegation of fraud may be continued until:
(1)  the investigation and any associated enforcement proceedings are complete; or
(2)  the Medicaid fraud control unit, another law enforcement agency, or another prosecuting authority determines that there is insufficient evidence of fraud by the provider that is the subject of the investigation.
(b)  If this state's Medicaid fraud control unit or another law enforcement agency declines to accept a fraud referral from the office of inspector general for investigation, a payment hold based on a credible allegation of fraud must be discontinued unless:
(1)  the commission has alternative federal or state authority under which the commission may impose a payment hold; or
(2)  the office makes a fraud referral to another law enforcement agency.
(c)  On a quarterly basis, the office of inspector general shall request a certification from this state's Medicaid fraud control unit and other law enforcement agencies as to whether each matter the unit or agency accepted on the basis of a credible allegation of fraud referral continues to be under investigation and that the continuation of a payment hold is warranted.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0257. Completion of Full Investigation of Alleged Medicaid Fraud or Abuse

Text of section effective on April 01, 2025
Sec. 544.0257.  COMPLETION OF FULL INVESTIGATION OF ALLEGED MEDICAID FRAUD OR ABUSE.  (a)  The office of inspector general 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.
(b)  Except as otherwise provided by this subsection, if the office of inspector general determines that more time is needed to complete a full 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.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0258. Memorandum of Understanding for Assisting Attorney General Investigations Related to Medicaid

Text of section effective on April 01, 2025
Sec. 544.0258.  MEMORANDUM OF UNDERSTANDING FOR ASSISTING ATTORNEY GENERAL INVESTIGATIONS RELATED TO MEDICAID.  (a)  The commission and the attorney general shall enter into a memorandum of understanding under which the commission shall:
(1)  provide investigative support to the attorney general as required in connection with cases under Subchapter B, Chapter 36, Human Resources Code; and
(2)  assist in performing preliminary investigations and ongoing investigations for actions the attorney general prosecutes under Subchapter C, Chapter 36, Human Resources Code.
(b)  The memorandum of understanding must specify the type, scope, and format of the investigative support the commission provides to the attorney general.
(c)  The memorandum of understanding must ensure that barriers to direct fraud referrals to this state's Medicaid fraud control unit by Medicaid agencies or unreasonable impediments to communication between Medicaid agency employees and the Medicaid fraud control unit are not imposed.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter F. Investigation of Fraud, Waste, Abuse, and Overcharges › Section 544.0259. Subpoenas

Text of section effective on April 01, 2025
Sec. 544.0259.  SUBPOENAS.  (a)  The office of inspector general may issue a subpoena in connection with an investigation the office conducts.  The subpoena may be:
(1)  issued to compel the attendance of a relevant witness or the production, for inspection or copying, of relevant evidence in this state; and
(2)  served personally or by certified mail.
(b)  The office of inspector general, acting through the attorney general, may file suit in a district court in this state to enforce a subpoena with which a person fails to comply.  On finding that good cause exists for issuing the subpoena, the court shall order the person to comply with the subpoena.  The court may punish a person who fails to obey the court order.
(c)  Reimbursement of the expenses of a witness whose attendance is compelled under this section is governed by Section 2001.103.
(d)  The office of inspector general shall pay a reasonable fee for subpoenaed photocopies.  The fee may not exceed the amount the office of inspector general may charge for copies of its records.
(e)  Except for the disclosure of information to the state auditor's office, law enforcement agencies, and other entities as permitted by other law, all information and materials subpoenaed or compiled by the office of inspector general in connection with an audit, inspection, or investigation or by the office of the attorney general in connection with a Medicaid fraud investigation are:
(1)  confidential and not subject to disclosure under Chapter 552; and
(2)  not subject to disclosure, discovery, subpoena, or other means of legal compulsion for release to anyone other than the office of inspector general, the attorney general, or the office's or attorney general's employees or agents involved in the audit, inspection, or investigation.
(f)  A person who receives information under Subsection (e) may disclose the information only in accordance with Subsection (e) and in a manner that is consistent with the authorized purpose for which the person first received the information.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter G. Payment Holds › Section 544.0301. Imposition of Payment Hold

Text of section effective on April 01, 2025
Sec. 544.0301.  IMPOSITION OF PAYMENT HOLD.  (a)  As authorized by state and federal law and except as provided by Subsections (d) and (e), the office of inspector general shall impose, as a serious enforcement tool to mitigate ongoing financial risk to this state, a payment hold on claims for reimbursement submitted by a provider only:
(1)  to compel production of records;
(2)  when requested by this state's Medicaid fraud control unit; or
(3)  on the determination that a credible allegation of fraud exists, subject to Sections 544.0104(b) and 544.0105(b), as applicable.
(b)  The office of inspector general shall impose a payment hold under this section without prior notice, and the payment hold takes effect immediately.
(c)  The office of inspector general shall, in consultation with this state's Medicaid fraud control unit, establish guidelines regarding the imposition of payment holds authorized under this section.
(d)  On the determination that a credible allegation of fraud exists and in accordance with 42 C.F.R. Sections 455.23(e) and (f), the office of inspector general 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:
(1)  law enforcement officials specifically requested that a payment hold not be imposed because a payment hold would compromise or jeopardize an investigation;
(2)  available remedies implemented by this state other than a payment hold would more effectively or quickly protect Medicaid funds;
(3)  the office of inspector general 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;
(4)  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:
(A)  is the sole community physician or the sole source of essential specialized services in a community; or
(B)  serves a large number of Medicaid recipients within a designated medically underserved area;
(5)  the attorney general declines to certify that a matter continues to be under investigation; or
(6)  the office of inspector general determines that a full or partial payment hold is not in the best interests of Medicaid.
(e)  Unless the office of inspector general has evidence that a provider materially misrepresented documentation relating to medically necessary services, the office of inspector general may not impose a payment hold on claims for reimbursement the provider submits for those services if the provider obtained prior authorization from the commission or a commission contractor.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter G. Payment Holds › Section 544.0302. Notice

Text of section effective on April 01, 2025
Sec. 544.0302.  NOTICE.  (a)  The office of inspector general shall notify a provider of a payment hold imposed under Section 544.0301(a) 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.
(b)  In addition to the requirements of 42 C.F.R. Section 455.23(b), the payment hold notice must also include:
(1)  the specific basis for the hold, including:
(A)  the claims supporting the allegation at that point in the investigation;
(B)  a representative sample of any documents that form the basis for the hold; and
(C)  a detailed summary of the office of inspector general's evidence relating to the allegation;
(2)  a description of administrative and judicial due process rights and remedies, including:
(A)  the provider's option to seek informal resolution;
(B)  the provider's right to seek a formal administrative appeal hearing; or
(C)  the provider's ability to seek both an informal resolution and a formal administrative appeal hearing; and
(3)  a detailed timeline for the provider to pursue the rights and remedies described in Subdivision (2).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter G. Payment Holds › Section 544.0303. Expedited Administrative Hearing

Text of section effective on April 01, 2025
Sec. 544.0303.  EXPEDITED ADMINISTRATIVE HEARING.  (a)  A provider subject to a payment hold imposed under Section 544.0301(a), other than a hold this state's Medicaid fraud control unit requested, must request an expedited administrative hearing not later than the 10th day after the date the provider receives notice of the hold from the office of inspector general under Section 544.0302.
(b)  On a provider's timely written request, the office of inspector general shall, not later than the third day after the date the office of inspector general receives the request, file a request with the State Office of Administrative Hearings for an expedited administrative hearing regarding the payment hold for which the provider submitted the request.
(c)  Not later than the 45th day after the date the State Office of Administrative Hearings receives a request from the office of inspector general for an expedited administrative hearing, the State Office of Administrative Hearings shall hold the hearing.
(d)  In an expedited administrative hearing held under this section:
(1)  the provider and the office of inspector general are each limited to four hours of testimony, excluding time for responding to questions from the administrative law judge;
(2)  the provider and the office of inspector general are each entitled to two continuances under reasonable circumstances; and
(3)  the office of inspector general is required to show probable cause that:
(A)  the credible allegation of fraud that is the basis of the imposed payment hold has an indicia of reliability; and
(B)  continuing to pay the provider presents an ongoing significant financial risk to this state and a threat to the integrity of Medicaid.
(e)  The office of inspector general is responsible for the costs of the expedited administrative hearing, but a provider is responsible for the provider's own costs incurred in preparing for the hearing.
(f)  In the expedited administrative hearing, the administrative law judge shall decide whether the payment hold should continue but may not adjust the amount or percent of the payment hold.
(g)  Notwithstanding any other law, including Section 2001.058(e), the administrative law judge's decision in the expedited administrative hearing is final and may not be appealed.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter G. Payment Holds › Section 544.0304. Informal Resolution

Text of section effective on April 01, 2025
Sec. 544.0304.  INFORMAL RESOLUTION.  (a)  The executive commissioner, in consultation with the office of inspector general, shall adopt rules that allow a provider subject to a payment hold imposed under Section 544.0301(a), other than a hold this state's Medicaid fraud control unit requested, to seek an informal resolution of the issues the office identifies in the notice provided under Section 544.0302.
(b)  A provider must request an initial informal resolution meeting under this section not later than the deadline prescribed by Section 544.0303(a) for requesting an expedited administrative hearing.
(c)  On receipt of a timely request, the office of inspector general shall:
(1)  decide whether to grant the provider's request for an initial informal resolution meeting; and
(2)  if the office decides to grant the request, schedule the initial informal resolution meeting and give notice to the provider of the time and place of the meeting.
(d)  A provider may request a second informal resolution meeting after the date of an initial informal resolution meeting.  On receipt of a timely request, the office of inspector general shall:
(1)  decide whether to grant the provider's request for a second informal resolution meeting; and
(2)  if the office decides to grant the request, schedule the second informal resolution meeting and give notice to the provider of the time and place of the second meeting.
(e)  Before a second informal resolution meeting is held, a provider must have an opportunity to provide additional information for the office of inspector general to consider.
(f)  A provider's decision to seek an informal resolution under this section does not extend the time by which the provider must request an expedited administrative hearing under Section 544.0303(a).  The informal resolution process shall run concurrently with the administrative hearing process, and the informal resolution process shall be discontinued when the State Office of Administrative Hearings issues a final determination on the payment hold.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter G. Payment Holds › Section 544.0305. Website Posting

Text of section effective on April 01, 2025
Sec. 544.0305.  WEBSITE POSTING.  The office of inspector general shall post on the office's publicly available Internet website a description in plain English of, and a video explaining, the processes and procedures the office uses to determine whether to impose a payment hold on a provider under this subchapter.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter H. Managed Care Organization Prevention and Investigation of Fraud and Abuse › Section 544.0351. Applicability of Subchapter

Text of section effective on April 01, 2025
Sec. 544.0351.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a managed care organization that provides or arranges for the provision of health care services to an individual under a government-funded program, including Medicaid and the child health plan program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter H. Managed Care Organization Prevention and Investigation of Fraud and Abuse › Section 544.0352. Special Investigative Unit or Contracted Entity to Investigate Fraud and Abuse

Text of section effective on April 01, 2025
Sec. 544.0352.  SPECIAL INVESTIGATIVE UNIT OR CONTRACTED ENTITY TO INVESTIGATE FRAUD AND ABUSE.  (a)  A managed care organization to which this subchapter applies shall:
(1)  establish and maintain a special investigative unit within the organization to investigate fraudulent claims and other types of program abuse by recipients or enrollees, as applicable, and service providers; or
(2)  contract with another entity to investigate fraudulent claims and other types of program abuse by recipients or enrollees, as applicable, and service providers.
(b)  A managed care organization that contracts for the investigation of fraudulent claims and other types of program abuse by recipients or enrollees, as applicable, and service providers under Subsection (a)(2) shall file with the office of inspector general:
(1)  a copy of the written contract;
(2)  the names, addresses, telephone numbers, and fax numbers of the principals of the entity with which the organization contracts; and
(3)  a description of the qualifications of the principals of the entity with which the organization contracts.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter H. Managed Care Organization Prevention and Investigation of Fraud and Abuse › Section 544.0353. Fraud and Abuse Prevention Plan

Text of section effective on April 01, 2025
Sec. 544.0353.  FRAUD AND ABUSE PREVENTION PLAN.  (a)  A managed care organization to which this subchapter applies shall:
(1)  adopt a plan to prevent and reduce fraud and abuse; and
(2)  annually file the plan with the office of inspector general for approval.
(b)  The plan must include:
(1)  a description of the organization's procedures for:
(A)  detecting and investigating possible acts of fraud or abuse;
(B)  mandatory reporting of possible acts of fraud or abuse to the office of inspector general; and
(C)  educating and training personnel to prevent fraud and abuse;
(2)  the name, address, telephone number, and fax number of the individual responsible for carrying out the plan;
(3)  a description or chart outlining the organizational arrangement of the organization's personnel responsible for investigating and reporting possible acts of fraud or abuse;
(4)  a detailed description of the results of fraud and abuse investigations the organization's special investigative unit or the entity with which the organization contracts under Section 544.0352(a)(2) conducts; and
(5)  provisions for maintaining the confidentiality of any patient information relevant to a fraud or abuse investigation.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter H. Managed Care Organization Prevention and Investigation of Fraud and Abuse › Section 544.0354. Assistance and Oversight by Office of Inspector General

Text of section effective on April 01, 2025
Sec. 544.0354.  ASSISTANCE AND OVERSIGHT BY OFFICE OF INSPECTOR GENERAL.  (a)  The office of inspector general may review the records of a managed care organization to which this subchapter applies to determine compliance with this subchapter.
(b)  The 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 to which this subchapter applies;
(2)  establish requirements for providing training to and regular oversight of special investigative units established by managed care organizations under Section 544.0352(a)(1) and entities with which managed care organizations contract under Section 544.0352(a)(2);
(3)  establish requirements for approving plans to prevent and reduce fraud and abuse that managed care organizations adopt under Section 544.0353;
(4)  evaluate statewide Medicaid fraud, waste, and abuse trends and communicate those trends to special investigative units and contracted entities to determine the prevalence of those trends;
(5)  as needed, assist managed care organizations in discovering or investigating fraud, waste, and abuse; 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, recipients, and enrollees.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.