Sec. 531.113. MANAGED CARE ORGANIZATIONS: SPECIAL INVESTIGATIVE UNITS OR CONTRACTS. (a) Each 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, shall:
(1) establish and maintain a special investigative unit within the managed care organization to investigate fraudulent claims and other types of program abuse by recipients and service providers; or
(2) contract with another entity for the investigation of fraudulent claims and other types of program abuse by recipients and service providers.
(b) Each managed care organization subject to this section shall adopt a plan to prevent and reduce fraud and abuse and annually file that plan with the commission's office of inspector general for approval. The plan must include:
(1) a description of the managed care organization's procedures for detecting and investigating possible acts of fraud or abuse;
(2) a description of the managed care organization's procedures for the mandatory reporting of possible acts of fraud or abuse to the commission's office of inspector general;
(3) a description of the managed care organization's procedures for educating and training personnel to prevent fraud and abuse;
(4) the name, address, telephone number, and fax number of the individual responsible for carrying out the plan;
(5) a description or chart outlining the organizational arrangement of the managed care organization's personnel responsible for investigating and reporting possible acts of fraud or abuse;
(6) a detailed description of the results of investigations of fraud and abuse conducted by the managed care organization's special investigative unit or the entity with which the managed care organization contracts under Subsection (a)(2); and
(7) provisions for maintaining the confidentiality of any patient information relevant to an investigation of fraud or abuse.
(c) If a managed care organization contracts for the investigation of fraudulent claims and other types of program abuse by recipients and service providers under Subsection (a)(2), the managed care organization shall file with the commission's 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 managed care organization has contracted; and
(3) a description of the qualifications of the principals of the entity with which the managed care organization has contracted.
(d) The commission's office of inspector general may review the records of a managed care organization to determine compliance with this section.
(d-1) The commission's office of inspector general, in consultation with the commission, shall:
(1) investigate, including by means of regular audits, possible fraud, waste, and abuse by managed care organizations subject to this section;
(2) establish requirements for the provision of training to and regular oversight of special investigative units established by managed care organizations under Subsection (a)(1) and entities with which managed care organizations contract under Subsection (a)(2);
(3) establish requirements for approving plans to prevent and reduce fraud and abuse adopted by managed care organizations under Subsection (b);
(4) evaluate statewide fraud, waste, and abuse trends in Medicaid and communicate those trends to special investigative units and contracted entities to determine the prevalence of those trends;
(5) assist managed care organizations in discovering or investigating fraud, waste, and abuse, as needed; and
(6) provide ongoing, regular training to appropriate commission and office staff concerning fraud, waste, and abuse in a managed care setting, including training relating to fraud, waste, and abuse by service providers and recipients.
(e) The executive commissioner, in consultation with the office, shall adopt rules as necessary to accomplish the purposes of this section, including rules defining the investigative role of the commission's office of inspector general with respect to the investigative role of special investigative units established by managed care organizations under Subsection (a)(1) and entities with which managed care organizations contract under Subsection (a)(2). The rules adopted under this section must specify the office's role in:
(1) reviewing the findings of special investigative units and contracted entities;
(2) investigating cases in which the overpayment amount sought to be recovered exceeds $100,000; and
(3) investigating providers who are enrolled in more than one managed care organization.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.25(a), eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.151, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 6, eff. September 1, 2015.
Section: Previous 531.1062 531.108 531.109 531.110 531.111 531.1112 531.112 531.113 531.1131 531.1132 531.114 531.115 531.116 531.117 531.118 NextLast modified: September 28, 2016