1-1 By: Giddings (Senate Sponsor - Armbrister) H.B. No. 1778
1-2 (In the Senate - Received from the House April 19, 1999;
1-3 April 20, 1999, read first time and referred to Committee on
1-4 Economic Development; May 14, 1999, reported adversely, with
1-5 favorable Committee Substitute by the following vote: Yeas 4, Nays
1-6 0; May 14, 1999, sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR H.B. No. 1778 By: Armbrister
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to the medical review of health care provided under the
1-11 workers' compensation insurance system.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Section 408.023, Labor Code, is amended to read
1-14 as follows:
1-15 Sec. 408.023. LIST OF APPROVED DOCTORS. (a) Each doctor
1-16 licensed in this state on January 1, 1993, is on the commission's
1-17 list of approved doctors unless subsequently deleted and not
1-18 reinstated. The name of a doctor shall be placed on the list of
1-19 approved doctors when that doctor becomes licensed in this state.
1-20 A doctor not licensed in this state but licensed in another state
1-21 or jurisdiction who treats employees may apply to the commission to
1-22 be included on the list. The executive director shall delete from
1-23 the list a doctor who is deceased, who requests to be deleted, or
1-24 whose license has been suspended or revoked.
1-25 (b) The commission shall establish criteria for deleting a
1-26 doctor from the list of approved doctors, for imposing sanctions on
1-27 a doctor as provided by this section as a condition of continued
1-28 approved doctor practice privileges, and for authorizing reduced
1-29 utilization review controls. The criteria for deleting a doctor
1-30 from the list or for imposing sanctions may include anything the
1-31 commission considers relevant, including:
1-32 (1) a sanction [sanctions] of the doctor by the
1-33 commission for a violation [violations] of Chapter 413 or Chapter
1-34 415;
1-35 (2) a sanction [sanctions] by the Medicare or Medicaid
1-36 program for:
1-37 (A) substandard medical care;
1-38 (B) overcharging; [or]
1-39 (C) overutilization of medical services; or
1-40 (D) any other noncompliance with that program in
1-41 professional practice or billing;
1-42 (3) evidence from the commission's medical records
1-43 that the insurance carrier's utilization review practices or that a
1-44 doctor's charges, fees, diagnoses, [or] treatments, evaluations, or
1-45 impairment ratings are unjustifiably [substantially] different from
1-46 those the commission finds to be fair and reasonable; [and]
1-47 (4) suspension of the doctor's license by an [the]
1-48 appropriate licensing authority;
1-49 (5) professional failure to practice medicine in an
1-50 acceptable manner consistent with the public health and welfare;
1-51 and
1-52 (6) the findings of fact and conclusions of law of a
1-53 court, an administrative law judge of the State Office of
1-54 Administrative Hearings, or a licensing or regulatory authority or
1-55 a criminal conviction.
1-56 (c) The commission shall establish by rule procedures under
1-57 which [for] a doctor may [to] apply for reinstatement to the list
1-58 or for restoration of privileges removed based on sanctions.
1-59 (d) Each doctor performing functions under this subtitle,
1-60 including required medical examinations under Section 408.004 and
1-61 medical utilization review evaluations, must be on the list of
1-62 approved doctors to perform services under this subtitle or to
1-63 receive payment for services.
1-64 (e) The commission may grant exceptions to the requirement
2-1 imposed under Subsection (d) as necessary to ensure that employees
2-2 have access to medical care. The commission may allow an
2-3 out-of-state doctor to perform utilization review services on
2-4 behalf of an insurance carrier if the doctor and insurance carrier
2-5 agree to make the doctor available for civil or administrative
2-6 proceedings as if the doctor were a resident of this state.
2-7 (f) Notwithstanding Section 402.072, the executive director
2-8 may, on a recommendation by the medical advisor and after notice
2-9 and the opportunity for a hearing, impose sanctions on a health
2-10 care provider, an insurance carrier, or a utilization review agent
2-11 under this section. The sanctions may include:
2-12 (1) reduction of allowable reimbursement;
2-13 (2) mandatory preauthorization of all or certain
2-14 medical services;
2-15 (3) required peer review monitoring and audits;
2-16 (4) temporary suspension or deletion from the approved
2-17 doctor list and the designated doctor list;
2-18 (5) restrictions on appointment as a required medical
2-19 examination doctor under Section 408.004; and
2-20 (6) temporary suspension of a utilization review
2-21 agent's ability to perform functions under this subtitle.
2-22 SECTION 2. Section 413.051, Labor Code, is amended to read
2-23 as follows:
2-24 Sec. 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH
2-25 CARE PROVIDERS. (a) The commission may contract with a health
2-26 care provider professional review organization, health care
2-27 provider, or other entity to develop, maintain, or review medical
2-28 policies or fee guidelines or to review compliance with the medical
2-29 policies or fee guidelines.
2-30 (b) For purposes of review or resolution of a dispute as to
2-31 compliance with the medical policies or fee guidelines, the
2-32 commission may contract [only] with a health care provider
2-33 professional review organization, health care provider, or other
2-34 entity that includes in the review process health care
2-35 practitioners who are licensed in the category under review and are
2-36 of the same field or specialty as the category under review.
2-37 (c) The commission may contract with a health care provider
2-38 professional review organization, health care provider, or other
2-39 entity for medical consultant services, including:
2-40 (1) independent medical examinations;
2-41 (2) medical case reviews; or
2-42 (3) establishment of medical policies and fee
2-43 guidelines.
2-44 (d) The commission shall establish standards for contracts
2-45 under this section.
2-46 SECTION 3. Subchapter E, Chapter 413, Labor Code, is amended
2-47 by adding Section 413.0515 to read as follows:
2-48 Sec. 413.0515. MEDICAL ADVISOR. (a) The commission shall
2-49 employ a medical advisor to:
2-50 (1) develop, maintain, and review medical policies and
2-51 fee guidelines, including medical policies regarding the
2-52 determination of impairment ratings;
2-53 (2) review compliance with those medical policies and
2-54 fee guidelines;
2-55 (3) perform other acts related to medical benefits as
2-56 required by the commission; and
2-57 (4) recommend, at least annually, the removal of
2-58 doctors from the commission's list of approved doctors under
2-59 Section 408.023 for any reason outlined in Section 408.023(b) or
2-60 for noncompliance with any policies reviewed under this section.
2-61 (b) The medical advisor may establish a panel of health care
2-62 providers to assist the medical advisor.
2-63 (c) The panel shall be independent of the medical advisory
2-64 committee created under Section 413.005. The panel consists of:
2-65 (1) three doctors experienced in workers' compensation
2-66 practice, from recommendations from established medical and
2-67 chiropractic associations, including two physicians and one doctor
2-68 of chiropractic;
2-69 (2) three doctors representing the insurance or
3-1 employer community who are experienced in medical utilization or
3-2 medical finance from recommendations from employer and insurance
3-3 associations; and
3-4 (3) a nonvoting attorney representative to advise the
3-5 panel.
3-6 (d) The medical advisor may cast the deciding vote in the
3-7 event of a tie among the members of the medical quality review
3-8 panel.
3-9 (e) The panel shall recommend to the medical advisor
3-10 appropriate action to sanction health care providers and
3-11 utilization review agents and to add, suspend, or delete doctors
3-12 from the list of approved doctors or the list of designated
3-13 doctors.
3-14 (f) Except for harm resulting from acts or omissions
3-15 involving gross neglect, malice, or recklessness, an individual
3-16 health care provider is not liable for recommendations for sanction
3-17 made pursuant to Subsection (e).
3-18 (g) Information that is confidential under law may not be
3-19 disclosed except:
3-20 (1) in a criminal proceeding;
3-21 (2) in a hearing conducted by or on behalf of the
3-22 commission;
3-23 (3) in a hearing conducted by another licensing or
3-24 regulatory authority, as provided in the interagency agreement; or
3-25 (4) on a finding of good cause in an administrative or
3-26 judicial proceeding involving the enforcement of this subtitle or
3-27 in a disciplinary action under this subtitle.
3-28 (h) Confidential information developed by the commission is
3-29 not subject to discovery or court subpoena in any other action
3-30 other than to enforce the provisions of this subtitle by the
3-31 commission, the appropriate licensing or regulatory agency, or the
3-32 appropriate enforcement authority, or in a criminal proceeding.
3-33 (i) Except for harm resulting from acts or omissions
3-34 involving gross neglect, malice, or recklessness, a health care
3-35 provider serving on a panel pursuant to Subsection (b) is not
3-36 liable for acts or omissions committed within the course and scope
3-37 of duties and responsibilities on the panel. The person's actions
3-38 do not constitute utilization review and are not subject to Article
3-39 21.58A, Insurance Code.
3-40 (j) The medical advisor must be a doctor as that term is
3-41 defined by Section 401.011.
3-42 SECTION 4. This Act takes effect September 1, 1999.
3-43 SECTION 5. The importance of this legislation and the
3-44 crowded condition of the calendars in both houses create an
3-45 emergency and an imperative public necessity that the
3-46 constitutional rule requiring bills to be read on three several
3-47 days in each house be suspended, and this rule is hereby suspended.
3-48 * * * * *