HB2886 - Relating to administrative remedies for certain fraud and abuse violations under Medicaid; providing administrative penalties.

  89R18109 JG-D     By: Noble H.B. No. 2886     Substitute the following for H.B. No. 2886:     By:  Hull C.S.H.B. No. 2886       A BILL TO BE ENTITLED   AN ACT   relating to administrative remedies for certain fraud and abuse   violations under Medicaid; providing administrative penalties.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Sections 544.0205(a) and (b), Government Code,   as effective April 1, 2025, are amended to read as follows:          (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 a remedy [ 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   remedy [ 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.          SECTION 2.  The heading to Section 32.039, Human Resources   Code, is amended to read as follows:          Sec. 32.039.   ADMINISTRATIVE REMEDIES [ DAMAGES AND   PENALTIES ].          SECTION 3.  Section 32.039(a), Human Resources Code, is   amended by amending Subdivision (1) and adding Subdivision (3-a) to   read as follows:                (1)  "Claim" means an application , request, or demand   for a benefit or payment [ of health care services ] under Title XIX   of the [ federal ] Social Security Act (42 U.S.C. Section 1396 et   seq.) [ that is submitted by a person who is under a contract or   provider agreement with the commission ].                 (3-a) "Material" means having a natural tendency to   influence or to be capable of influencing.          SECTION 4.  Section 32.039, Human Resources Code, is amended   by adding Subsections (a-1), (a-2), (c-1), and (c-2) and amending   Subsections (b), (c), (d), (f), (g), (h), (i), (k), (l), (m), (n),   (o), (p), (q), (r), (s), and (x) to read as follows:           (a-1)     For purposes of this section, a person acts knowingly   with respect to information if the person:                 (1)  has knowledge of the information;                 (2)     acts with conscious indifference to the truth or   falsity of the information; or                 (3)     acts in reckless disregard of the truth or falsity   of the information.           (a-2)     Proof of the person's specific intent to commit a   violation under this section is not required in a civil or   administrative proceeding to show that the person acted "knowingly"   with respect to information under this section.          (b)  A person commits a violation if the person:                (1)   knowingly submits [ presents ] or causes to be   submitted [ presented to the commission ] a claim that contains :                       (A)   a false statement ;                       (B)  a misrepresentation;  or                       (C)  an omission of a material fact   [ representation the person knows or should know to be false ];                 (2)  [ (1-a) ]  engages in conduct that violates Section   102.001, Occupations Code;                 (3)  [ (1-b) ]  solicits or receives, directly or   indirectly, overtly or covertly any remuneration, including any   kickback, bribe, or rebate, in cash or in kind for referring an   individual to a person for the furnishing of, or for arranging the   furnishing of, any item or service for which payment may be made, in   whole or in part, under the medical assistance program, provided   that this subdivision does not prohibit the referral of a patient to   another practitioner within a multispecialty group or university   medical services research and development plan (practice plan) for   medically necessary services;                 (4)  [ (1-c) ]  solicits or receives, directly or   indirectly, overtly or covertly any remuneration, including any   kickback, bribe, or rebate, in cash or in kind for purchasing,   leasing, or ordering, or arranging for or recommending the   purchasing, leasing, or ordering of, any good, facility, service,   or item for which payment may be made, in whole or in part, under the   medical assistance program;                 (5)  [ (1-d) ]  offers or pays, directly or indirectly,   overtly or covertly any remuneration, including any kickback,   bribe, or rebate, in cash or in kind to induce a person to refer an   individual to another person for the furnishing of, or for   arranging the furnishing of, any item or service for which payment   may be made, in whole or in part, under the medical assistance   program, provided that this subdivision does not prohibit the   referral of a patient to another practitioner within a   multispecialty group or university medical services research and   development plan (practice plan) for medically necessary services;                 (6)  [ (1-e) ]  offers or pays, directly or indirectly,   overtly or covertly any remuneration, including any kickback,   bribe, or rebate, in cash or in kind to induce a person to purchase,   lease, or order, or arrange for or recommend the purchase, lease, or   order of, any good, facility, service, or item for which payment may   be made, in whole or in part, under the medical assistance program;                 (7)  [ (1-f) ]  provides, offers, or receives an   inducement in a manner or for a purpose not otherwise prohibited by   this section or Section 102.001, Occupations Code, to or from a   person, including a recipient, provider, employee or agent of a   provider, third-party vendor, or public servant, for the purpose of   influencing or being influenced in a decision regarding:                      (A)  selection of a provider or receipt of a good   or service under the medical assistance program;                      (B)  the use of goods or services provided under   the medical assistance program; or                      (C)  the inclusion or exclusion of goods or   services available under the medical assistance program;                 (8)     knowingly makes or causes to be made a false   statement or misrepresentation of a material fact to permit a   person to receive a benefit or payment under the medical assistance   program that is not authorized or that is greater than the benefit   or payment that is authorized;                 (9)     knowingly conceals or fails to disclose   information that permits a person to receive a benefit or payment   under the medical assistance program that is not authorized or that   is greater than the benefit or payment that is authorized;                 (10)     knowingly applies for and receives a benefit or   payment on behalf of another person under the medical assistance   program and converts any part of the benefit or payment to a use   other than for the benefit of the person on whose behalf it was   received;                 (11)     knowingly makes, causes to be made, induces, or   seeks to induce the making of a false statement or   misrepresentation of a material fact concerning the conditions or   operation of a facility in order that the facility may qualify for   certification or recertification under the medical assistance   program, including certification or recertification as:                       (A)  a hospital;                       (B)     a nursing facility or skilled nursing   facility;                       (C)  a hospice provider;                       (D)     an intermediate care facility for   individuals with an intellectual disability;                       (E)  an assisted living facility; or                       (F)  a home and community support services agency;                 (12)     knowingly makes, causes to be made, induces, or   seeks to induce the making of a false statement or   misrepresentation of a material fact concerning information   required to be provided under a federal or state law, rule,   regulation, or provider agreement pertaining to the medical   assistance program;                 (13)     knowingly presents or causes to be presented a   claim for payment for a product provided or a service rendered by a   person who:                       (A)     is not licensed to provide the product or   render the service, if a license is required; or                       (B)  is not licensed in the manner claimed;                 (14)  knowingly makes or causes to be made a claim for:                       (A)     a service or product that has not been   approved or accepted by a treating physician or health care   practitioner;                       (B)     a service or product that is substantially   inadequate or inappropriate as compared to generally recognized   standards within the particular discipline or within the health   care industry; or                       (C)     a product that has been adulterated, debased,   or mislabeled, or that is otherwise inappropriate;                 (15)     makes a claim and knowingly fails to indicate the   type of license of the provider who actually provided the service;                 (16)     makes a claim and knowingly fails to indicate the   identification number of the licensed provider who actually   provided the service;                 (17)     knowingly obstructs the office of inspector &#xA0 [Text truncated for display. 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