Relating to the review of claims and recovery of overpayments by Medicaid recovery audit contractors.

89(R) HB 3984 - Engrossed version - Bill Text

89R23116 CMO-D

By: Oliverson

H.B. No. 3984

A BILL TO BE ENTITLED

AN ACT

relating to the review of claims and recovery of overpayments by

Medicaid recovery audit contractors.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 544.0504, Government Code, is amended to

read as follows:

Sec. 544.0504. RECOVERY AUDIT CONTRACTORS.
(a)
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 to
:

(1)
identify Medicaid underpayments and overpayments
,

including underpayments and overpayments under the Medicaid

managed care program;
and

(2)
recover the overpayments.

(b)

An overpayment under Subsection (a)(2) may be recovered

from either the provider or the managed care organization.

(c) A recovery audit contractor may not:

(1) initiate a review of a claim unless:

(A)

the office of inspector general or the

office's designee:

(i)

determines that the review would be

cost-effective; and

(ii) approves the review; and

(B)

at least one year has elapsed since the date

the claim was received; or

(2)

initiate a recovery effort on a claim if a managed

care organization has notified the office of inspector general that

the organization is auditing the claim.

(d)

On request by a recovery audit contractor or the office

of inspector general, a managed care organization or provider who

is the subject of a review conducted under this section shall submit

to the contractor or office all information necessary to perform

the review not later than the date specified in the request.

All

information and materials obtained under this section are

confidential under Section 544.0259(e).

(e)

The executive commissioner by rule shall adopt a process

for appeals related to overpayments identified by a recovery audit

contractor under this section.

(f)

The commission may contract with a third party to

administer Subsection (b) or the appeals process adopted under

Subsection (e).

(g)

The executive commissioner, in consultation with the

office of inspector general, may adopt rules necessary to implement

this section.

SECTION 2. If before implementing any provision of this Act

a state agency determines that a waiver or authorization from a

federal agency is necessary for implementation of that provision,

the agency affected by the provision shall request the waiver or

authorization and may delay implementing that provision until the

waiver or authorization is granted.

SECTION 3. The Health and Human Services Commission is

required to implement the changes in law made by this Act to Section

544.0504, Government Code, only if the legislature appropriates

money specifically for that purpose. If the legislature does not

appropriate money specifically for that purpose, the commission

may, but is not required to, implement those changes in law using

other money available to the commission for that purpose.

SECTION 4. This Act takes effect September 1, 2025.