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Texas Statutes (Last Updated: January 4, 2014) |
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GOVERNMENT CODE |
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Title 4. EXECUTIVE BRANCH |
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Subtitle I. HEALTH AND HUMAN SERVICES |
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Chapter 531. HEALTH AND HUMAN SERVICES COMMISSION |
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Subchapter C. MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD, ABUSE, OR OVERCHARGES |
Sec. 531.1063. MEDICAID FRAUD PILOT PROGRAM
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(a) The commission, with cooperation from the Texas Department of Human Services, shall develop and implement a front-end Medicaid fraud reduction pilot program in one or more counties in this state to address provider fraud and appropriate cases of third-party and recipient fraud.
(b) The program must be designed to reduce:
(1) the number of fraud cases arising from authentication fraud and abuse;
(2) the total amount of Medicaid expenditures; and
(3) the number of fraudulent participants.
(c) The program must include:
(1) participant smart cards and biometric readers that reside at the point of contact with Medicaid providers, recipients, participating pharmacies, hospitals, and appropriate third-party participants;
(2) a secure finger-imaging system that is compliant with the Health Insurance Portability and Accountability Act (HIPAA) and the use of any existing state database of fingerprint images developed in connection with the financial assistance program under Chapter 31, Human Resources Code; fingerprint images collected as part of the program shall only be placed on the smart card; and
(3) a monitoring system.
(d) In implementing the program, the commission may:
(1) exempt recipients who are children or who are elderly or disabled; and
(2) obtain a fingerprint image from a parent or caretaker of a recipient who is a child, regardless of whether the parent or caretaker is a recipient.
(e) The commission must ensure that the procedures for obtaining fingerprint images of participating recipients and parents and caretakers who are not recipients are designed in a flexible manner that gives consideration to transportation barriers and work schedules of those individuals.
(f) To ensure reliability, the program and all associated hardware and software must easily integrate into participant settings and must be initially tested in a physician environment in this state and determined to be successful in authenticating recipients, providers, and provider staff members before the program is implemented throughout the program area.
(g) The commission shall implement the program statewide as provided by Subsection (h) if the commission determines that statewide implementation would be cost-effective.
(h) The commission shall adopt a plan to implement the program statewide in phases and shall terminate the statewide implementation at any stage of the process if the commission determines that statewide implementation would not be cost-effective. The plan must include for each phase:
(1) a description of the policies and procedures to be tested concerning the handling of lost, forgotten, or stolen cards carrying a fingerprint image or situations in which a fingerprint match cannot be confirmed;
(2) a determination of whether the commission will require children or persons who are elderly or disabled to participate in the phase and the reason or reasons for including children or persons who are elderly or disabled in the phase; and
(3) a description of the manner and location in which the fingerprint images will be initially collected.
(i) In developing the plan required by Subsection (h), the commission shall seek comments from recipients, providers, and other stakeholders in the state Medicaid program.