SRC-JEC S.B. 1411 77(R)   BILL ANALYSIS


Senate Research Center   S.B. 1411
77R2349 KKA-DBy: Moncrief
Health & Human Services
3/29/2001
As Filed


DIGEST AND PURPOSE 

An interim investigation by the House Committee on General Investigating
found evidence of misconduct by some providers in the Texas Health Steps
Dental Services Program, involving the aggressive use of certain dental
procedures and fraudulent billing procedures.  As proposed, S.B. 1411
addresses these abuses by implementing changes recommended by the committee
to reduce fraud and improve the quality of services and care offered by the
program. 

RULEMAKING AUTHORITY

Rulemaking authority is expressly granted to the Health and Human Services
Commission or an agency operating part of the medical assistance program,
as appropriate, in SECTION 1 (Section 32.053, Human Resources Code) of this
bill. 

SECTION BY SECTION ANALYSIS

SECTION 1.  Amends Chapter 32B, Human Resources Code, by adding Section
32.053, as follows: 

Sec. 32.053.  DENTAL SERVICES. (a)  Requires the Health and Human Services
Commission or an agency operating part of the medical assistance program,
as appropriate (department), in providing dental services under the medical
assistance program, to: 

(1)  ensure that a stainless steel crown is used only when medically
necessary and not as a preventive measure; 

(2)  require a dentist participating in the medical assistance program to
document, through x-rays or other methods established by department rule,
the medical necessity for a stainless steel crown before the crown is
applied; 

(3)  require a dentist participating in the medical assistance program to
comply with a minimum standard of documentation and record-keeping for each
of the dentist's patients, regardless of whether the patient's costs are
paid privately or through the medical assistance program; 

(4)  replace the 15-point system used for determining the medical necessity
for hospitalization and general anesthesia with a more objective and
comprehensive system developed by the department; and 

(5)  take all necessary action to eliminate fraud in the provision of
dental services under the medical assistance program, including adopting a
zero tolerance policy toward fraud, aggressively investigating and
prosecuting any dentist who abuses the system for reimbursement under the
medical assistance program, and randomly auditing all dentists
participating in the medical assistance program and conducting targeted
audits of dentists whose billing activities under the medical assistance
program are excessive or otherwise  inconsistent with the billing
activities of other similarly situated dentists. 

(b)  Requires the department, in setting reimbursement rates for dental
services under the medical assistance program, to: 

(1)  reduce the amount of the hospitalization fee in effect on December 1,
2000, and redistribute amounts made available through reduction of that fee
to other commonly billed dental services for which adequate accountability
measures exist; and 

(2)  eliminate the behavior management fee and the nutritional consultation
fee and redistribute amounts made available through elimination of those
fees to other commonly billed dental services for which adequate
accountability measures exist. 

(c)  Requires the department to develop the minimum standard described by
Subsection (a)(3) in cooperation with the State Board of Dental Examiners. 

SECTION 2.  Requires a state agency, if before implementing any provision
of this Act it determines that a waiver or authorization from a federal
agency is necessary for implementation of that provision, to request the
waiver or authorization and authorizes the agency to delay implementing
that provision until the waiver or authorization is granted. 

SECTION 3.  Effective date: upon passage or September 1, 2001.