reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1025. Performance Audits and Coordination of Audit Activities

Sec. 531.1025.  PERFORMANCE AUDITS AND COORDINATION OF AUDIT ACTIVITIES.
Text of subsection effective until January 01, 2025
(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.
Text of subsection effective until January 01, 2025
(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.
(c)  The commission's office of inspector general shall conduct performance audits and require financial audits to be conducted of each local behavioral health authority designated under Section 533.0356, Health and Safety Code, and local mental health authority, as defined by Section 531.002, Health and Safety Code.  The office shall:
(1)  establish a performance audit schedule that ensures the office audits each authority described by this subsection at least once every five years;
(2)  establish a financial audit schedule that ensures each authority described by this subsection:
(A)  undergoes a financial audit conducted by an independent auditor at least once every three years; and
(B)  submits to the office the results of the financial audit; and
(3)  require additional audits to be conducted as necessary based on adverse findings in a previous audit or as requested by the commission.
Added by Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 11, eff. September 1, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 1035 (S.B. 26), Sec. 5, eff. September 1, 2023.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1033. Monitoring of Certain Federal Databases

Text of section effective until April 01, 2025
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.
Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.15(b), eff. September 1, 2015.
Added by Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 5, eff. September 1, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1034. Time to Determine Provider Eligibility; Performance Metrics

Text of section effective until April 01, 2025
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.
Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.15(b), eff. September 1, 2015.
Added by Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 5, eff. September 1, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.104. Assisting Investigations by Attorney General

Text of section effective until April 01, 2025
Sec. 531.104.  ASSISTING INVESTIGATIONS BY ATTORNEY GENERAL.  (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 specify the type, scope, and format of the investigative support provided to the attorney general under this section.
(c)  The memorandum of understanding must ensure that no barriers to direct fraud referrals to the state's Medicaid fraud control unit by Medicaid agencies or unreasonable impediments to communication between Medicaid agency employees and the state's Medicaid fraud control unit will be imposed.
Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.06(a), eff. Sept. 1, 1997.  Amended by Acts 2003 78th Leg., ch. 198, Sec. 2.22, eff. Sept. 1, 2003;  Acts 2003, 78th Leg., ch. 257, Sec. 11, eff. Sept. 1, 2003.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.105. Fraud Detection Training

Text of section effective until April 01, 2025
Sec. 531.105.  FRAUD DETECTION TRAINING.  (a)  The commission shall develop and implement a program to provide annual training to contractors who process Medicaid claims and to appropriate staff of the health and human services agencies in identifying potential cases of fraud, waste, or abuse under Medicaid.  The training provided to the contractors and staff 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.
(b)  The health and human services agencies, in cooperation with the commission, shall periodically set a goal of the number of potential cases of fraud, waste, or abuse under Medicaid 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).
Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.06(a), eff. Sept. 1, 1997.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.139, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.106. Learning, Neural Network, or Other Technology

Text of section effective until April 01, 2025
Sec. 531.106.  LEARNING, NEURAL NETWORK, OR OTHER TECHNOLOGY.  (a)  The commission shall use learning, neural network, or other technology to identify and deter fraud in Medicaid 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 data 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 Medicaid 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 inspector general or the office of the attorney general, as appropriate.
(g)  Each month, the technology implemented under this section must match vital statistics unit 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 vital statistics unit death records, the commission shall refer the case for investigation to the commission's office of inspector general.
Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.06(a), eff. June 20, 1997.  Amended by Acts 1999, 76th Leg., ch. 215, Sec. 2, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.140, eff. April 2, 2015.
Acts 2017, 85th Leg., R.S., Ch. 277 (H.B. 2379), Sec. 3, eff. May 29, 2017.
Acts 2017, 85th Leg., R.S., Ch. 277 (H.B. 2379), Sec. 4, eff. May 29, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1061. Fraud Investigation Tracking System

Text of section effective until April 01, 2025
Sec. 531.1061.  FRAUD INVESTIGATION TRACKING SYSTEM.  (a)  The commission shall use an automated fraud investigation tracking system through the commission's office of inspector general to monitor the progress of an investigation of suspected fraud, abuse, or insufficient quality of care under Medicaid.
(b)  For each case of suspected fraud, abuse, or insufficient quality of care identified by the technology required under Section 531.106, the automated fraud investigation tracking system must:
(1)  receive electronically transferred records relating to the identified case from the technology;
(2)  record the details and monitor the status of an investigation of the identified case, including maintaining a record of the beginning and completion dates for each phase of the case investigation;
(3)  generate documents and reports related to the status of the case investigation; and
(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 Medicaid to participate in the implementation and use of the automated fraud investigation tracking system.
Added by Acts 1999, 76th Leg., ch. 206, Sec. 1, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.141, eff. April 2, 2015.
Acts 2017, 85th Leg., R.S., Ch. 277 (H.B. 2379), Sec. 5, eff. May 29, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1062. Recovery Monitoring System

Text of section effective until April 01, 2025
Sec. 531.1062.  RECOVERY MONITORING SYSTEM.  (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 Medicaid.
(b)  The recovery monitoring system must:
(1)  monitor the collection of funds resulting from settled cases, including:
(A)  recording monetary payments received from a provider who has agreed to a monetary payment plan;  and
(B)  recording deductions taken through the recoupment program from subsequent Medicaid claims filed by the provider;  and
(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.
Added by Acts 1999, 76th Leg., ch. 206, Sec. 1, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.142, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.108. Fraud Prevention

Text of section effective until April 01, 2025
Sec. 531.108.  FRAUD PREVENTION.  (a)  The commission's 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 case management system or the case management system of a health and human services agency.
(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 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.
(d)  The commission shall:
(1)  verify automobile information that is used as criteria for eligibility;  and
(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)  Not later than October 1 of each year, the commission shall submit to the governor and Legislative Budget Board an annual 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.
Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.06(a), eff. Sept. 1, 1997.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 1312 (S.B. 59), Sec. 38, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.144, eff. April 2, 2015.
Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 8, eff. September 1, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1081. Integrity of Certain Public Assistance Programs

Text of section effective until April 01, 2025
Sec. 531.1081.  INTEGRITY OF CERTAIN PUBLIC ASSISTANCE PROGRAMS.  (a)  In this section:
(1)  "Financial assistance benefits" means money payments under the federal Temporary Assistance for Needy Families program operated under Chapter 31, Human Resources Code, or under the state temporary assistance and support services program operated under Chapter 34, Human Resources Code.
(2)  "Supplemental nutrition assistance benefits" means money payments under the supplemental nutrition assistance program operated under Chapter 33, Human Resources Code.
(b)  To the extent not otherwise provided by this subtitle or Title 2, Human Resources Code, the commission shall develop and implement, in accordance with this section, methods for reducing abuse, fraud, and waste in public assistance programs.
(c)  On a monthly basis, the commission shall:
(1)  conduct electronic data matches with the Texas Lottery Commission to determine if a recipient of supplemental nutrition assistance benefits or a recipient's household member received reportable lottery winnings;
(2)  use the database system developed under Section 531.0214 to match vital statistics unit death records with a list of individuals eligible for financial assistance or supplemental nutrition assistance benefits, and ensure that any individual receiving assistance under either program who is discovered deceased has their eligibility for assistance promptly terminated; and
(3)  review the out-of-state electronic benefit transfer card transactions made by a recipient of supplemental nutrition assistance benefits to determine whether those transactions indicate a possible change in the recipient's residence.
(d)  The commission shall immediately review the eligibility of a recipient of public assistance benefits if the commission discovers information under this section that affects the recipient's eligibility.
(e)  A  recipient who fails to disclose lottery winnings that are required to be reported to the commission under a public assistance program presumptively commits a program violation.
(f)  The executive commissioner shall adopt rules necessary to implement this section.
Added by Acts 2021, 87th Leg., R.S., Ch. 879 (S.B. 1341), Sec. 1, eff. September 1, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.109. Selection and Review of Claims

Text of section effective until April 01, 2025
Sec. 531.109.  SELECTION AND REVIEW OF CLAIMS.  (a)  The commission shall annually select and review a random, statistically valid sample of all claims for reimbursement under Medicaid, including under the vendor drug program, for potential cases of fraud, waste, or abuse.
(b)  In conducting the annual review of claims under Subsection (a), the commission may directly contact a recipient by telephone or in person, or both, to verify that the services for which a claim for reimbursement was submitted by a provider 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 at 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 under this section only after the commission has completed the prior year's annual review of claims.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 4, eff. Sept. 1, 1999.
Amended by:
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.04(c), eff. September 28, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.145, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.110. Electronic Data Matching Program

Text of section effective until April 01, 2025
Sec. 531.110.  ELECTRONIC DATA MATCHING PROGRAM.  (a)  In this section,  "public assistance program" includes:
(1)  Medicaid;
(2)  the financial assistance program under Chapter 31, Human Resources Code; and
(3)  a nutritional assistance program under Chapter 33, Human Resources Code, including the supplemental nutrition assistance program under that chapter.
(a-1)  The commission shall conduct electronic data matches for a recipient of benefits under a public assistance program at least quarterly to verify the identity, income, employment status, and other factors that affect the eligibility of the recipient.
(b)  To verify eligibility of a recipient of public assistance program benefits, the electronic data matching must match information provided by the recipient with information contained in databases maintained by appropriate federal and state agencies.
(c)  The health and human services agencies shall cooperate with the commission by providing data or any other assistance necessary to conduct the electronic data matches required by this section.
(c-1)  The commission shall enter into a memorandum of understanding with each state agency from which data is required to conduct electronic data matches under this section and Section 531.1081.
(d)  The commission may contract with a public or private entity to conduct the electronic data matches required by this section.
(e)  The executive commissioner shall establish procedures by which the commission, or a health and human services agency designated by the commission, verifies the electronic data matches conducted by the commission under this section.  Not later than the 20th day after the date the electronic data match is verified, the commission shall remove from eligibility a recipient who is determined to be ineligible for a public assistance program.
(f)  Repealed by Acts 2011, 82nd Leg., R.S., Ch. 1083, Sec. 25(59), eff. June 17, 2011.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 4, eff. Sept. 1, 1999.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 1050 (S.B. 71), Sec. 21(8), eff. September 1, 2011.
Acts 2011, 82nd Leg., R.S., Ch. 1083 (S.B. 1179), Sec. 25(59), eff. June 17, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.146, eff. April 2, 2015.
Acts 2021, 87th Leg., R.S., Ch. 879 (S.B. 1341), Sec. 2, eff. September 1, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.111. Fraud Detection Technology

Text of section effective until April 01, 2025
Sec. 531.111.  FRAUD DETECTION TECHNOLOGY.  The commission may contract with a contractor who specializes in developing technology capable of identifying patterns of fraud exhibited by Medicaid recipients to:
(1)  develop and implement the fraud detection technology; and
(2)  determine if a pattern of fraud by Medicaid recipients is present in the recipients' eligibility files maintained by the commission.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 4, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.147, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1112. Study Concerning Increased Use of Technology to Strengthen Fraud Detection and Deterrence; Implementation

Text of section effective until April 01, 2025
Sec. 531.1112.  STUDY CONCERNING INCREASED USE OF TECHNOLOGY TO STRENGTHEN FRAUD DETECTION AND DETERRENCE; IMPLEMENTATION.  (a)  The commission and the commission's office of inspector general shall jointly study the feasibility of increasing the use of technology to strengthen the detection and deterrence of fraud in Medicaid.  The study must include the determination of the feasibility of using technology to verify a person's citizenship and eligibility for coverage.
(b)  The commission shall implement any methods the commission and the commission's office of inspector general determine are effective at strengthening fraud detection and deterrence.
Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 6(a), eff. September 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.148, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.112. Expunction of Information Related to Certain Chemical Dependency Diagnoses in Certain Records

Text of section effective until April 01, 2025
Sec. 531.112.  EXPUNCTION OF INFORMATION RELATED TO CERTAIN CHEMICAL DEPENDENCY DIAGNOSES IN CERTAIN RECORDS.  (a)  In this section:
(1)  "Chemical dependency" has the meaning assigned by Section 461A.002, Health and Safety Code.
(2)  "Child" means a person 13 years of age or younger.
(b)  Following the final conviction of a chemical dependency treatment provider for an offense, an element of which involves submitting a fraudulent claim for reimbursement for services under Medicaid, the commission or other health and human services agency that operates a portion of Medicaid shall expunge or provide for the expunction of a diagnosis of chemical dependency in a child that has been made by the treatment provider and entered in any:
(1)  appropriate official record of the commission or agency;
(2)  applicable medical record that is in the commission's or agency's custody; and
(3)  applicable record of a company that the commission contracts with for the processing and payment of claims under Medicaid.
Added by Acts 2001, 77th Leg., ch. 1081, Sec. 1, eff. Sept. 1, 2001.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.149, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.150, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1132. Annual Report on Certain Fraud and Abuse Recoveries

Text of section effective until April 01, 2025
Sec. 531.1132.  ANNUAL REPORT ON CERTAIN FRAUD AND ABUSE RECOVERIES.  Not later than December 1 of each year, the commission shall prepare and submit a report to the legislature relating to the amount of money recovered during the preceding 12-month period as a result of investigations and recovery efforts made under Sections 531.113 and 531.1131 by special investigative units or entities with which a managed care organization contracts under Section 531.113(a)(2). The report must specify the amount of money retained by each managed care organization under Section 531.1131(c).
Added by Acts 2011, 82nd Leg., R.S., Ch. 980 (H.B. 1720), Sec. 7, eff. September 1, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1135. Managed Care Organizations: Process to Recoup Certain Overpayments

Text of section effective until April 01, 2025
Sec. 531.1135.  MANAGED CARE ORGANIZATIONS:  PROCESS TO RECOUP CERTAIN OVERPAYMENTS.  (a)  The executive commissioner shall adopt rules that standardize the process by which a managed care organization collects alleged overpayments that are made to a health care provider and discovered through an audit or investigation conducted by the organization secondary to missing electronic visit verification information.  In adopting rules under this section, the executive commissioner shall require that the managed care organization:
(1)  provide written notice of the organization's intent to recoup overpayments not later than the 30th day after the date an audit is complete; and
(2)  limit the duration of audits to 24 months.
(b)  The executive commissioner shall require that the notice required under this section inform the provider:
(1)  of the specific claims and electronic visit verification transactions that are the basis of the overpayment;
(2)  of the process the provider should use to communicate with the managed care organization to provide information about the electronic visit verification transactions;
(3)  of the provider's option to seek an informal resolution of the alleged overpayment;
(4)  of the process to appeal the determination that an overpayment was made; and
(5)  if the provider intends to respond to the notice, that the provider must respond not later than the 30th day after the date the provider receives the notice.
(c)  Notwithstanding any other law, a managed care organization may not attempt to recover an overpayment described by Subsection (a) until the provider has exhausted all rights to an appeal.
Added by Acts 2019, 86th Leg., R.S., Ch. 667 (S.B. 1991), Sec. 3, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.114. Financial Assistance Fraud

Text of section effective until April 01, 2025
Sec. 531.114.  FINANCIAL ASSISTANCE FRAUD.  (a)  For purposes of establishing or maintaining the eligibility of a person and the person's family for financial assistance under Chapter 31, Human Resources Code, or for purposes of increasing or preventing a reduction in the amount of that assistance, a person may not intentionally:
(1)  make a statement that the person knows is false or misleading;
(2)  misrepresent, conceal, or withhold a fact;  or
(3)  knowingly misrepresent a statement as being true.
(b)  If after an investigation the commission determines that a person violated Subsection (a), the commission shall:
(1)  notify the person of the alleged violation not later than the 30th day after the date the commission completes the investigation and provide the person with an opportunity for a hearing on the matter;  or
(2)  refer the matter to the appropriate prosecuting attorney for prosecution.
(c)  If a person waives the right to a hearing or if a hearing officer at an administrative hearing held under this section determines that a person violated Subsection (a), the person is ineligible to receive financial assistance as provided by Subsection (d).  A person who a hearing officer determines violated Subsection (a) may appeal that determination by filing a petition in the district court in the county in which the violation occurred not later than the 30th day after the date the hearing officer made the determination.
(d)  A person determined under Subsection (c) to have violated Subsection (a) is not eligible for financial assistance:
(1)  before the first anniversary of the date of that determination, if the person has no previous violations;  and
(2)  permanently, if the person was previously determined to have committed a violation.
(e)  If a person is convicted of a state or federal offense for conduct described by Subsection (a), or if the person is granted deferred adjudication or placed on community supervision for that conduct, the person is permanently disqualified from receiving financial assistance.
(f)  This section does not affect the eligibility for financial assistance of any other member of the household of a person ineligible as a result of Subsection (d) or (e).
(g)  The executive commissioner shall adopt rules as necessary to implement this section.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.26(a), eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.153, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.115. Federal Felony Match

Text of section effective until April 01, 2025
Sec. 531.115.  FEDERAL FELONY MATCH.  The commission shall develop and implement a system to cross-reference data collected for the programs listed under Section 531.008(c) with the list of fugitive felons maintained by the federal government.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.27, eff. Sept. 1, 2003.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.116. Compliance With Law Prohibiting Solicitation

Text of section effective until April 01, 2025
Sec. 531.116.  COMPLIANCE WITH LAW PROHIBITING SOLICITATION.  A provider who furnishes services under Medicaid or the child health plan program is subject to Chapter 102, Occupations Code, and the provider's compliance with that chapter is a condition of the provider's eligibility to participate as a provider under those programs.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.28, eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.154, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.117. Recovery Audit Contractors

Text of section effective until April 01, 2025
Sec. 531.117.  RECOVERY AUDIT CONTRACTORS.  To the extent required under Section 1902(a)(42), Social Security Act (42 U.S.C. Section 1396a(a)(42)), the commission shall establish a program under which the commission contracts with one or more recovery audit contractors for purposes of identifying underpayments and overpayments under Medicaid and recovering the overpayments.
Added by Acts 2011, 82nd Leg., R.S., Ch. 980 (H.B. 1720), Sec. 7, eff. September 1, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.155, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.119. Website Posting

Text of section effective until April 01, 2025
Sec. 531.119.  WEBSITE POSTING.  The commission's office of inspector general shall post on its publicly available 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 2013, 83rd Leg., R.S., Ch. 622 (S.B. 1803), Sec. 3, eff. September 1, 2013.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.120. Notice and Informal Resolution of Proposed Recoupment of Overpayment or Debt

Text of section effective until April 01, 2025
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 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 request an informal resolution meeting under this section, and on receipt of the request, the office shall schedule the informal resolution meeting.  The office shall give notice to the provider of the time and place of the informal resolution meeting.  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.
(c)  The commission shall provide the notice required by Subsection (a) to a provider that is a hospital not later than the 90th day before the date the overpayment or debt that is the subject of the notice must be paid.
Added by Acts 2013, 83rd Leg., R.S., Ch. 622 (S.B. 1803), Sec. 3, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 8, eff. September 1, 2015.
Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 3, eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1201. Appeal of Determination to Recoup Overpayment or Debt

Text of section effective until April 01, 2025
Sec. 531.1201.  APPEAL OF DETERMINATION TO RECOUP OVERPAYMENT OR DEBT.  (a)  A provider must request an appeal under this section not later than the 30th 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)  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.
(c)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 945 , Sec. 13(1), eff. September 1, 2015.
(d)  Following an administrative hearing under Subsection (a), a provider who is the subject of a recoupment of overpayment or recoupment of debt arising out of a fraud or abuse investigation may appeal a final administrative order by filing a petition for judicial review in a district court in Travis County.
Added by Acts 2013, 83rd Leg., R.S., Ch. 622 (S.B. 1803), Sec. 3, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 9, eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 13(1), eff. September 1, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1202. Record and Confidentiality of Informal Resolution Meetings

Text of section effective until April 01, 2025
Sec. 531.1202.  RECORD AND CONFIDENTIALITY OF INFORMAL RESOLUTION MEETINGS.  (a)  On the written request of the provider, 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.
Added by Acts 2013, 83rd Leg., R.S., Ch. 622 (S.B. 1803), Sec. 3, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 10, eff. September 1, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges › Section 531.1203. Rights of and Provision of Information to Pharmacies Subject to Certain Audits

Text of section effective until April 01, 2025
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.
Added by Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 11, eff. September 1, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.