By Ellis H.B. No. 2282
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to certain audits of health benefit plan payments and
1-3 reimbursements to health care providers.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.75 to read as follows:
1-7 Art. 21.75. HEALTH BENEFIT PLAN PAYMENT AUDITS
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Health benefit plan" means a plan or arrangement
1-10 under which medical or surgical expenses are paid for or reimbursed
1-11 or health care services are provided or arranged to be provided.
1-12 The term includes:
1-13 (A) An individual, group, blanket, or franchise
1-14 insurance policy, insurance agreement, or group hospital service
1-15 contract, or an individual or group evidence of coverage that is
1-16 offered by:
1-17 (i) an insurance company;
1-18 (ii) a group hospital service corporation
1-19 operating under Chapter 20 of this code;
1-20 (iii) a fraternal benefit society
1-21 operating under Chapter 10 of this code;
1-22 (iv) a stipulated premium insurance
2-1 company operating under Chapter 22 of this code;
2-2 (v) a lloyd's plan insurer operating under
2-3 Chapter 18 of this code;
2-4 (vi) a health maintenance organization
2-5 operating under the Texas Health Maintenance Organization Act
2-6 (Chapter 20A of this code);
2-7 (vii) an approved nonprofit health
2-8 corporation that is certified under Section 5.01(a), Medical
2-9 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-10 that holds a certificate of authority issued by the commissioner
2-11 under Article 21.52F of this code;
2-12 (viii) notwithstanding Section 172.014,
2-13 Local Government Code, or any other law, provides health and
2-14 accident coverage through a risk pool created under Chapter 172,
2-15 Local Government Code.
2-16 (ix) a multiple employer welfare
2-17 arrangement as defined by Section 3, Employee Retirement Income
2-18 Security Act of 1974 (29 U.S.C. 1002) or another analogous benefit
2-19 arrangement to the extent permitted by the Employee Retirement
2-20 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.).
2-21 (B) The term "health benefit plan" does not
2-22 include:
2-23 (i) a plan that provides coverage:
2-24 (aa) only for accidental death or
2-25 dismemberment;
2-26 (bb) for wages or payments in lieu
3-1 of wages for a period during which an employee is absent from work
3-2 because of sickness or injury; or
3-3 (cc) as a supplement to liability
3-4 insurance;
3-5 (ii) workers' compensation insurance
3-6 coverage; or
3-7 (iii) medical payment insurance issued as
3-8 part of a motor vehicle insurance policy.
3-9 (2) "Health care provider" means a physician,
3-10 practitioner, institutional provider, or other person or
3-11 organization who, under a license or other grant of authority
3-12 issued by this state, provides health care services, treatment, or
3-13 supplies to individuals covered under a health benefit plan.
3-14 (3) "Institutional provider" means a hospital, nursing
3-15 home, or any other medical or health related service facility
3-16 caring for the sick or injured or providing care for other coverage
3-17 that may be provided under a health benefit plan.
3-18 (4) "Payment audit" means a review by the issuer of
3-19 the health benefit plan of payments or reimbursements that have
3-20 been made to a health care provider to determine if:
3-21 (A) the health care services, treatments, or
3-22 supplies that have been provided by the health care provider under
3-23 the health benefit plan were properly charged or
3-24 (B) the payments or reimbursements to the health
3-25 care providers for the health care services, treatments, or
3-26 supplies were properly paid.
4-1 (5) "Physician" means anyone licensed to practice
4-2 medicine in the State of Texas.
4-3 (6) "Practitioner" means a person other than a
4-4 physician who is licensed or otherwise authorized to provide health
4-5 care services in this state.
4-6 Sec. 2. TIME LIMITATION. Any payment audit that is conducted
4-7 by an issuer of a health benefit plan must be conducted within two
4-8 years from the date that the payments or reimbursements are made to
4-9 the health care provider.
4-10 Sec. 3. EXCEPTIONS. Section 2 shall not apply
4-11 (1) if the issuer of the health benefit plan obtains
4-12 information not previously available to the issuer that indicates
4-13 that the payment or reimbursement was made on the basis of false or
4-14 fraudulent information with regard to a material fact;
4-15 (2) if the issuer of the health benefit plan obtains
4-16 information not previously available to the issuer that voids or
4-17 cancels the health benefit plan coverage; or
4-18 (3) if the issuer of the health benefit plan and the
4-19 health care provider contract for the conduct of the payment audits
4-20 for a period of time that is less than two years from the date that
4-21 the payment or reimbursement is made to the health care provider.
4-22 SECTION 2. This Act takes effect September 1, 2001.
4-23 SECTION 3. This Act applies only to health benefit plan
4-24 payments or reimbursements made on or after the effective date of
4-25 this Act in those instances in which there is no contract between
4-26 the health care provider and the issuer of the health benefit plan
5-1 and applies only to a contract between a health care provider and
5-2 an issuer of a health benefit plan entered into or renewed on or
5-3 after the effective date of this Act. A contract entered into
5-4 before the effective date of this Act is governed by the law in
5-5 effect immediately before the effective date of this Act, and that
5-6 law is continued in effect for that purpose.
5-7 SECTION 4. The importance of this legislation and the crowded
5-8 condition of the calendars in both houses create an emergency and
5-9 an imperative public necessity that the constitutional rule
5-10 requiring bills to be read on three several days in each house be
5-11 suspended, and this rule is hereby suspended.