HBA-DMH C.S.S.B. 1143 77(R) BILL ANALYSIS Office of House Bill AnalysisC.S.S.B. 1143 By: Carona Insurance 4/26/2001 Committee Report (Substituted) BACKGROUND AND PURPOSE Currently, all contracts between health maintenance organizations (HMOs) and physicians or other providers require credentialing. The initial credentialing process includes an application, verification of information, and a site visit. Texas has not updated the standards on credentialing HMOs to stay in compliance with standards promulgated by the National Committee for Quality Assurance (NCQA). Medicaid and Medicare credentialing standards are based on NCQA standards. C.S.S.B. 1143 updates the credentialing standards to bring them into compliance with NCQA's standards. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority is expressly delegated to the commissioner of insurance in SECTION 2 (Section 2, Article 21.58D, Insurance Code) of this bill. ANALYSIS C.S.S.B. 1143 amends the Insurance Code to require the commissioner of insurance (commissioner) to require a health maintenance organization (HMO) to verify that a physician's license to practice medicine and any other certificate the physician is required to hold is valid as of the date of initial credentialing and on the date of each recredentialing. The bill requires the commissioner to require an HMO that conducts a site visit for the purpose of initial credentialing to evaluate during the visit a site's accessibility, appearance, space, medical or dental recordkeeping practices, availability of appointments, and confidentiality procedures. The bill prohibits the commissioner from requiring that an HMO: _evaluate the appropriateness of equipment during the site visit; _formally recredential physicians or providers more frequently than once in any three-year period; _verify the validity of a license or certificate held by a physician other than as of the date of initial credentialing or recredentialing of the physician; _use clinical personnel to perform a site visit for initial credentialing of a physician or provider unless clinical review is needed during the site visit; or _require a site visit be performed for recredentialing of a physician or provider. These provisions do not preclude an HMO from performing a site visit of a physician or provider at any time for cause. Rules adopted by the commissioner for HMO quality assurance that relate to implementation and maintenance by an HMO of a process for selecting and retaining affiliated physicians and providers must comply with this bill and standards promulgated by the National Committee for Quality Assurance, to the extent those standards do not conflict with other laws of this state. The bill requires the commissioner by rule to adopt a standardized form for the verification of the credentials of a physician and to require that a public or private hospital, an HMO or a preferred provider organization use the form for verification of credentials. In adopting a standardized form, the bill requires the commissioner to consider any credentialing application form that is widely used in this state. The bill requires the Texas State Board of Medical Examiners (TSBME) to study the establishment of a program for standardized credentials verification through using a credentialing information system. The bill requires TSBME, not later than January 1, 2003, to report on its recommendations for proposed legislation, based on the study, to the governor, the lieutenant governor, and the speaker of the house of representatives. EFFECTIVE DATE September 1, 2001. COMPARISON OF ORIGINAL TO SUBSTITUTE C.S.S.B. 1143 differs from the original bill by requiring the Texas State Board of Medical Examiners (TSBME) to study the establishment of a program for standardized credentials verification. The substitute requires the commissioner of insurance to adopt and require the use of a standardized form for the verification of physician credentials. The substitute requires the TSBME to report its recommendations to the governor and the legislature.