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.