By Brimer H.B. No. 1202
77R3661 PB-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the medical review of health care provided under the
1-3 workers' compensation insurance system.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter B, Chapter 408, Labor Code, is amended
1-6 by amending Section 408.023 and adding Section 408.0235 to read as
1-7 follows:
1-8 Sec. 408.023. LIST OF APPROVED DOCTORS. (a) The commission
1-9 shall develop a list of doctors who are approved to provide medical
1-10 care and services under this subtitle. Each doctor licensed in
1-11 this state [on January 1, 1993,] is eligible to be included on the
1-12 commission's list of approved doctors if the doctor:
1-13 (1) registers with the commission in the manner
1-14 prescribed by commission rules; and
1-15 (2) complies with the requirements adopted by the
1-16 commission under this section.
1-17 (b) The commission by rule shall establish reasonable
1-18 requirements for doctors who:
1-19 (1) provide services as treating doctors;
1-20 (2) provide services as designated doctors;
1-21 (3) perform medical peer review under this subtitle;
1-22 or
1-23 (4) perform utilization review of medical benefits
1-24 provided under this subtitle.
2-1 (c) The commission shall issue to a doctor who is approved
2-2 by the commission a certificate of registration. A certificate of
2-3 registration issued under this subsection is valid for four years
2-4 from the date of issuance, and may be renewed on application to the
2-5 commission [unless subsequently deleted and not reinstated. The
2-6 name of a doctor shall be placed on the list of approved doctors
2-7 when that doctor becomes licensed in this state].
2-8 (d) A doctor not licensed in this state but licensed in
2-9 another state or jurisdiction who treats employees may apply for a
2-10 certificate of registration under this section and [to the
2-11 commission] to be included on the commission's list of approved
2-12 doctors.
2-13 (e) Each doctor performing functions under this subtitle,
2-14 including required medical examinations under Section 408.004 and
2-15 medical utilization review evaluations, must hold a certificate of
2-16 registration and be on the list of approved doctors to perform
2-17 services under this subtitle or to receive payment for those
2-18 services.
2-19 (f) The commission may grant exceptions to the requirement
2-20 imposed under Subsection (e) as necessary to ensure that employees
2-21 have access to medical care. The commission may allow an
2-22 out-of-state doctor to perform utilization review services on
2-23 behalf of an insurance carrier if the doctor and insurance carrier
2-24 agree to make the doctor available for civil or administrative
2-25 proceedings as if the doctor were a resident of this state.
2-26 Sec. 408.0235. DELETION FROM LIST OF APPROVED DOCTORS;
2-27 SANCTIONS. (a) The executive director shall delete from the list a
3-1 doctor who is deceased or who requests to be removed from the list.
3-2 (b) The commission by rule shall establish criteria for:
3-3 (1) deleting a doctor from the list of approved
3-4 doctors;
3-5 (2) imposing sanctions on a doctor as provided by this
3-6 section; and
3-7 (3) authorizing reduced utilization review controls.
3-8 (c) The rules adopted under Subsection (b) are in addition
3-9 to, and do not affect, the rules adopted under Section 415.023(b).
3-10 The criteria for deleting a doctor from the list or for imposing
3-11 sanctions may include anything the commission considers relevant,
3-12 including:
3-13 (1) a sanction [sanctions] of the doctor by the
3-14 commission for a violation [violations] of Chapter 413 or Chapter
3-15 415;
3-16 (2) a sanction [sanctions] by the Medicare or Medicaid
3-17 program for:
3-18 (A) substandard medical care;
3-19 (B) overcharging; [or]
3-20 (C) overutilization of medical services; or
3-21 (D) any other noncompliance with that program in
3-22 professional practice or billing;
3-23 (3) evidence from the commission's medical records
3-24 that the applicable insurance carrier's utilization review
3-25 practices or the doctor's charges, fees, diagnoses, [or]
3-26 treatments, evaluations, or impairment ratings are unjustifiably
3-27 [substantially] different from those the commission finds to be
4-1 fair and reasonable; [and]
4-2 (4) suspension of the doctor's license by an [the]
4-3 appropriate licensing authority;
4-4 (5) professional failure to practice medicine in an
4-5 acceptable manner consistent with the public health and welfare;
4-6 and
4-7 (6) the findings of fact and conclusions of law of a
4-8 court, an administrative law judge from the State Office of
4-9 Administrative Hearings, or a licensing or regulatory authority or
4-10 a criminal conviction.
4-11 (d) [(c)] The commission by rule shall establish procedures
4-12 under which [for] a doctor may [to] apply for:
4-13 (1) reinstatement to the list of approved doctors; or
4-14 (2) restoration of doctor practice privileges removed
4-15 by the commission based on sanctions imposed under this section.
4-16 (e) Notwithstanding Section 402.072 and Article 21.58A,
4-17 Insurance Code, the executive director may, on a recommendation by
4-18 the medical advisor and after notice and the opportunity for a
4-19 hearing, impose sanctions under this subsection on a health care
4-20 provider, an insurance carrier, or a utilization review agent.
4-21 Those sanctions may include:
4-22 (1) reduction of allowable reimbursement;
4-23 (2) mandatory preauthorization of all or certain
4-24 medical services;
4-25 (3) required peer review monitoring and audits;
4-26 (4) temporary suspension or deletion from the approved
4-27 doctor list and the designated doctor list;
5-1 (5) restrictions on appointment as a required medical
5-2 examination doctor under Section 408.004;
5-3 (6) temporary suspension of a utilization review
5-4 agent's ability to perform functions under this subtitle; and
5-5 (7) mandatory participation in training classes or
5-6 other courses as established or certified by the commission.
5-7 SECTION 2. Section 413.051, Labor Code, is amended to read as
5-8 follows:
5-9 Sec. 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH
5-10 CARE PROVIDERS. (a) The commission may contract with a health care
5-11 provider professional review organization, health care provider, or
5-12 other entity to develop, maintain, or review medical policies or
5-13 fee guidelines or to review compliance with the medical policies or
5-14 fee guidelines.
5-15 (b) For purposes of review or resolution of a dispute as to
5-16 compliance with the medical policies or fee guidelines, the
5-17 commission may contract [only] with a health care provider
5-18 professional review organization, health care provider, or other
5-19 entity that includes in the review process health care
5-20 practitioners who are licensed in the category under review and are
5-21 of the same field or specialty as the category under review.
5-22 (c) The commission may contract with a health care provider
5-23 professional review organization, health care provider, or other
5-24 entity for medical consultant services, including:
5-25 (1) independent medical examinations;
5-26 (2) medical case reviews; or
5-27 (3) establishment of medical policies and fee
6-1 guidelines.
6-2 (d) The commission shall establish standards for contracts
6-3 under this section.
6-4 SECTION 3. Subchapter E, Chapter 413, Labor Code, is amended
6-5 by adding Sections 413.0511, 413.0512, and 413.0513 to read as
6-6 follows:
6-7 Sec. 413.0511. MEDICAL ADVISOR. (a) The commission shall
6-8 employ or contract with a medical advisor, who must be a doctor as
6-9 that term is defined by Section 401.011.
6-10 (b) The medical advisor shall:
6-11 (1) develop, maintain, and review medical policies and
6-12 fee guidelines, including medical policies regarding the
6-13 determination of impairment ratings;
6-14 (2) review compliance with those medical policies and
6-15 fee guidelines;
6-16 (3) perform other acts related to medical benefits as
6-17 required by the commission; and
6-18 (4) recommend, at least annually, the deletion of
6-19 doctors from the commission's list of approved doctors under
6-20 Section 408.023 for:
6-21 (A) any reason described by Section 408.0235; or
6-22 (B) noncompliance with a policy reviewed by the
6-23 medical advisor under this section.
6-24 Sec. 413.0512. MEDICAL QUALITY REVIEW PANEL. (a) The
6-25 medical advisor may establish a medical quality review panel of
6-26 health care providers as an advisory body to assist the medical
6-27 advisor. The panel is independent of the medical advisory
7-1 committee created under Section 413.005.
7-2 (b) The medical quality review panel shall recommend to the
7-3 medical advisor appropriate action to sanction health care
7-4 providers and utilization review agents and to add, suspend, or
7-5 delete doctors from the list of approved doctors or the group of
7-6 designated doctors established under Section 408.122.
7-7 (c) The Texas State Board of Medical Examiners and the Texas
7-8 State Board of Podiatric Medical Examiners shall develop lists of
7-9 physicians and chiropractors licensed by those agencies who have
7-10 demonstrated experience in workers' compensation or utilization
7-11 review. The medical advisor shall appoint the members of the
7-12 medical quality review panel from the names on those lists.
7-13 (d) In the event of a tie vote among the members of the
7-14 medical quality review panel, the medical advisor may cast the
7-15 deciding vote.
7-16 (e) Except for harm resulting from an act or omission
7-17 involving gross negligence, malice, or recklessness, a person who
7-18 serves on the medical quality review panel is not liable for an act
7-19 or omission committed in the course and scope of the person's
7-20 service as a member of the panel.
7-21 (f) The actions of a person serving on the medical quality
7-22 review panel do not constitute utilization review and are not
7-23 subject to Article 21.58A, Insurance Code.
7-24 Sec. 413.0513. CONFIDENTIALITY REQUIREMENTS. (a)
7-25 Information that is confidential under law may not be disclosed
7-26 under Section 413.0512 except:
7-27 (1) in a criminal proceeding;
8-1 (2) in a hearing conducted by or on behalf of the
8-2 commission;
8-3 (3) in a hearing conducted by another licensing or
8-4 regulatory authority, as provided in the interagency agreement; or
8-5 (4) on a finding of good cause in an administrative or
8-6 judicial proceeding involving the enforcement of this subtitle or
8-7 in a disciplinary action under this subtitle.
8-8 (b) Confidential information developed by the commission
8-9 under Section 413.0512 is not subject to discovery or court
8-10 subpoena in any action other than:
8-11 (1) an action to enforce this subtitle brought by the
8-12 commission, an appropriate licensing or regulatory agency, or an
8-13 appropriate enforcement authority; or
8-14 (2) a criminal proceeding.
8-15 SECTION 4. (a) This Act takes effect September 1, 2001.
8-16 (b) The Texas Workers' Compensation Commission shall adopt
8-17 rules as required by Chapter 408, Labor Code, as amended by this
8-18 Act, not later than December 1, 2001. A person is not required to
8-19 hold a certificate of registration issued under Section 408.023 to
8-20 perform medical services under Subtitle A, Title 5, Labor Code,
8-21 before March 1, 2002.