By:  Carona                                           S.B. No. 1143
                                A BILL TO BE ENTITLED
 1-1                                   AN ACT
 1-2     relating to the selection and retention of affiliated physicians
 1-3     and providers by health maintenance organizations.
 1-4           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
 1-5           SECTION 1.  The Texas Health Maintenance Organization Act
 1-6     (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding
 1-7     Section 39 to read as follows:
 1-8           Sec. 39.  CREDENTIALING OF PHYSICIANS AND PROVIDERS.
 1-9     (a)  Rules adopted by the commissioner under Section 37 of this Act
1-10     that relate to implementation and maintenance by a health
1-11     maintenance organization of a process for selecting and retaining
1-12     affiliated physicians and providers must comply with:
1-13                 (1)  this section; and
1-14                 (2)  standards promulgated by the National Committee
1-15     for Quality Assurance, to the extent those standards do not
1-16     conflict with other laws of this state.
1-17           (b)  The commissioner shall require a health maintenance
1-18     organization to verify that a physician's license to practice
1-19     medicine and any other certificate the physician is required to
1-20     hold, including a certificate issued by the Department of Public
1-21     Safety of the State of Texas or the federal Drug Enforcement Agency
1-22     or a certificate issued under the Medicare program, is valid as of
1-23     the date of initial credentialing and on the date of each
1-24     recredentialing.
1-25           (c)  The commissioner shall require a health maintenance
 2-1     organization that conducts a site visit for the purpose of initial
 2-2     credentialing to evaluate during the visit a site's accessibility,
 2-3     appearance, space, medical or dental recordkeeping practices,
 2-4     availability of appointments, and confidentiality procedures.  The
 2-5     commissioner may not require the health maintenance organization to
 2-6     evaluate the appropriateness of equipment during the site visit.
 2-7           (d)  The commissioner may not require that a health
 2-8     maintenance organization:
 2-9                 (1)  formally recredential physicians or providers more
2-10     frequently than once in any three-year period;
2-11                 (2)  verify the validity of a license or certificate
2-12     held by a physician other than as of the date of initial
2-13     credentialing or recredentialing of the physician;
2-14                 (3)  use clinical personnel to perform a site visit for
2-15     initial credentialing of a physician or provider unless clinical
2-16     review is needed during the site visit; or
2-17                 (4)  require a site visit be performed for
2-18     recredentialing of a physician or provider.
2-19           (e)  This section does not preclude a health maintenance
2-20     organization from performing a site visit of a physician or
2-21     provider at any time for cause, including a complaint made by a
2-22     member or another external complaint made to the health maintenance
2-23     organization.
2-24           SECTION 2.  This Act takes effect September 1, 2001.