bill expanding Medicaid recovery audits to managed care

The text as introduced · 376 words

89R15279 CMO-D

By: Hughes
S.B. No. 2458

A BILL TO BE ENTITLED

AN ACT

relating to the audit 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, as effective

April 1, 2025, 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) A recovery audit contractor may recover an overpayment

under Subsection (a)(2) from either the provider or the managed

care organization.

(c) To avoid duplicative recovery efforts on a claim, a

recovery audit contractor shall:

(1) notify the office of inspector general or the

office's designee prior to initiating a review of a claim under this

section; and

(2) if directed by the office, exclude a 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 an audit conducted under this section shall submit

to the contractor or office all information necessary to perform

the audit 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 (d) or (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. This Act takes effect September 1, 2025.