By:  Duncan                                           S.B. No. 1476
         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 medical and income benefits, return to work
 1-3     coordination, and regulation of doctors and insurance carriers
 1-4     under the workers' compensation system.
 1-6           SECTION 1.01.  Subchapter B, Chapter 408, Labor Code, is
 1-7     amended by amending Section 408.023 and adding Section 408.0231 to
 1-8     read as follows:
 1-9           Sec. 408.023.  List of Approved Doctors.  (a)  The commission
1-10     shall develop a list of Texas licensed doctors who are approved to
1-11     provide medical services under this subtitle.  Each doctor licensed
1-12     in this state [on January 1, 1993,] is eligible to be included on
1-13     the commission's list of approved doctors if the doctor:
1-14                 (1)  registers with the commission in the manner
1-15     prescribed by commission rules; and
1-16                 (2)  complies with the requirements adopted by the
1-17     commission under this section.
1-18           (b)  The commission by rule shall establish reasonable
1-19     training, impairment rating testing, financial interest disclosure,
1-20     and monitoring requirements for doctors and health care providers
1-21     financially related to those doctors who:
1-22                 (1)  provide services as treating doctors;
1-23                 (2)  provide services as authorized by Sections 408.004
 2-1     or 408.122;
 2-2                 (3)  perform medical peer review under this subtitle;
 2-3                 (4)  perform utilization review of medical benefits
 2-4     provided under this subtitle; and
 2-5                 (5)  provide medical services on referral from the
 2-6     treating doctor as provided by commission rule.
 2-7           (c)  The commission shall issue to a doctor who is approved
 2-8     by the commission a certificate of registration.  A certificate of
 2-9     registration issued under this subsection is valid for four years
2-10     from the date of issuance or as may be provided by commission rule,
2-11     and may be renewed on application to the commission [unless
2-12     subsequently deleted and not reinstated.  The name of a doctor
2-13     shall be placed on the list of approved doctors when that doctor
2-14     becomes licensed in this state].
2-15           (d)  A doctor not licensed in this state but licensed in
2-16     another state or jurisdiction who treats employees may apply for a
2-17     certificate of registration under this section [to the commission]
2-18     to be included on the commission's list of approved doctors.
2-19           (e)  Each doctor performing functions under this subtitle,
2-20     including examinations under Sections 408.004 and 408.122 and
2-21     medical utilization review evaluations, must hold a certificate of
2-22     registration and be on the list of approved doctors in order to
2-23     perform services or receive payment for those services.
2-24           (f)  The commission may grant exceptions to the requirement
2-25     imposed under Subsection (e) as necessary to ensure that employees
2-26     have access to medical care.
 3-1           (g)  The treating doctor is responsible for the efficient
 3-2     management of medical care as required by Section 408.025(c) and
 3-3     commission rules, whether that care is provided directly or by a
 3-4     provider on referral from the treating doctor.  The commission
 3-5     shall capture information regarding return to work outcomes,
 3-6     patient satisfaction, and cost and utilization of medical services
 3-7     provided or authorized by a treating doctor on the list of approved
 3-8     doctors.
 3-9           Sec. 408.0231.  DELETION FROM LIST OF APPROVED DOCTORS;
3-10     SANCTIONS.  (a)  The executive director shall delete from the list
3-11     a doctor who is deceased, whose license to practice in this state
3-12     is revoked by the appropriate licensing board, or who requests to
3-13     be removed from the list.
3-14           (b)  The commission by rule shall establish criteria for:
3-15                 (1)  deleting a doctor from the list of approved
3-16     doctors;
3-17                 (2)  imposing sanctions on a doctor as provided by this
3-18     section; and
3-19                 (3)  authorizing reduced utilization review and
3-20     preauthorization controls on a doctor.
3-21           (c)  The rules adopted under Subsection (b) are in addition
3-22     to, and do not affect, the rules adopted under Section 415.023(b).
3-23     The criteria for deleting a doctor from the list or for imposing
3-24     sanctions may include anything the commission considers relevant,
3-25     including:
3-26                 (1)  a sanction [sanctions] of the doctor by the
 4-1     commission for a violation [violations] of Chapter 413 or Chapter
 4-2     415;
 4-3                 (2)  a sanction [sanctions] by the Medicare or Medicaid
 4-4     program for:
 4-5                       (A)  substandard medical care;
 4-6                       (B)  overcharging; [or]
 4-7                       (C)  overutilization of medical services; or
 4-8                       (D)  any other noncompliance with that program in
 4-9     professional practice or billing;
4-10                 (3)  evidence from the commission's medical records
4-11     that the applicable insurance carrier's utilization review
4-12     practices or the doctor's charges, fees, diagnoses, [or]
4-13     treatments, evaluations, or impairment ratings are unjustifiably
4-14     [substantially] different from those the commission finds to be
4-15     fair and reasonable; [and]
4-16                 (4)  suspension of the doctor's license by an [the]
4-17     appropriate licensing authority;
4-18                 (5)  professional failure to practice medicine in an
4-19     acceptable manner consistent with the public health and welfare;
4-20     and
4-21                 (6)  the findings of fact and conclusions of law of a
4-22     court, an administrative law judge from the State Office of
4-23     Administrative Hearings, or a licensing or regulatory authority, or
4-24     a criminal conviction.
4-25           (d) [(c)]  The commission by rule shall establish procedures
4-26     under which [for] a doctor may [to] apply for:
 5-1                 (1)  reinstatement to the list of approved doctors; or
 5-2                 (2)  restoration of doctor practice privileges removed
 5-3     by the commission based on sanctions imposed under this section.
 5-4           (e)  Notwithstanding Article 21.58A, Insurance Code, the
 5-5     commission may, on a recommendation by the medical advisor and
 5-6     after notice and the opportunity for a hearing, impose sanctions
 5-7     under this subsection on a doctor, an insurance carrier, or a
 5-8     utilization review agent.  Those sanctions may include:
 5-9                 (1)  reduction of allowable reimbursement;
5-10                 (2)  mandatory preauthorization of all or certain
5-11     medical services;
5-12                 (3)  required peer review monitoring and audit with the
5-13     doctor bearing responsibility for the reasonable cost of monitoring
5-14     and audit;
5-15                 (4)  suspension or deletion from the approved doctor
5-16     list and the designated doctor list;
5-17                 (5)  restrictions on appointment under Section 408.004;
5-18                 (6)  suspension of an insurance carrier or utilization
5-19     review agent's ability to perform functions under this subtitle;
5-20     and
5-21                 (7)  mandatory participation in training classes or
5-22     other courses as established or certified by the commission.
5-23           SECTION 1.02.  Subchapter E, Chapter 413, Labor Code, is
5-24     amended by amending Section 413.051 and adding Sections 413.0511,
5-25     413.0512 and 413.0513 to read as follows:
 6-1     CARE PROVIDERS.  (a)  The commission may contract with a health
 6-2     care provider professional review organization, health care
 6-3     provider, or other entity to develop, maintain, or review medical
 6-4     policies or fee guidelines or to review compliance with the medical
 6-5     policies or fee guidelines.
 6-6           (b)  For purposes of review or resolution of a dispute as to
 6-7     compliance with the medical policies or fee guidelines, the
 6-8     commission may contract [only] with a health care provider
 6-9     professional review organization, health care provider, or other
6-10     entity that includes in the review process health care
6-11     practitioners who are licensed in the category under review and are
6-12     of the same field or specialty as the category under review.
6-13           (c)  The commission may contract with a health care provider
6-14     professional review organization, health care provider, or other
6-15     entity for medical consultant services, including:
6-16                 (1)  independent medical examinations;
6-17                 (2)  medical case reviews; or
6-18                 (3)  establishment of medical policies and fee
6-19     guidelines.
6-20           (d)  The commission shall establish standards for contracts
6-21     under this section.
6-22           Sec. 413.0511.  MEDICAL ADVISOR.  (a)  The commission shall
6-23     employ or contract with a medical advisor, who must be a doctor as
6-24     that term is defined by Section 401.011.
6-25           (b)  The medical advisor shall:
6-26                 (1)  develop, maintain, and review medical policies and
 7-1     fee guidelines, including medical policies regarding the
 7-2     determination of impairment ratings;
 7-3                 (2)  review compliance with those medical policies and
 7-4     fee guidelines;
 7-5                 (3)  perform other acts related to medical benefits as
 7-6     required by the commission; and
 7-7                 (4)  recommend sanction or deletion of doctors from the
 7-8     commission's list of approved doctors under Section 408.023 for:
 7-9                       (A)  any reason described by Section 408.0235; or
7-10                       (B)  noncompliance with a policy reviewed by the
7-11     medical advisor under this section.
7-12           Sec. 413.0512.  MEDICAL QUALITY REVIEW PANEL.  (a)  The
7-13     medical advisor may establish a medical quality review panel of
7-14     health care providers as an advisory body to assist the medical
7-15     advisor.  The panel is independent of the medical advisory
7-16     committee created under Section 413.005.
7-17           (b)  The medical quality review panel shall recommend to the
7-18     medical advisor appropriate action to sanction health care
7-19     providers and utilization review agents and to add, suspend, or
7-20     delete doctors from the list of approved doctors or the group of
7-21     designated doctors established under Section 408.122.
7-22           (c)  The Texas State Board of Medical Examiners and the Texas
7-23     State Board of Chiropractic Medical Examiners shall develop lists
7-24     of physicians and chiropractors licensed by those agencies who have
7-25     demonstrated experience in workers' compensation or utilization
7-26     review.  The medical advisor shall appoint some of the members of
 8-1     the medical quality review panel from the names on those lists.
 8-2           (d) [(e)]  Except for harm resulting from an act or omission
 8-3     involving gross negligence, malice, or recklessness, a person who
 8-4     serves on the medical quality review panel is not liable for an act
 8-5     or omission committed in the course and scope of the person's
 8-6     service as a member of the panel.
 8-7           (e) [(f)]  The actions of a person serving on the medical
 8-8     quality review panel do not constitute utilization review and are
 8-9     not subject to Article 21.58A, Insurance Code.
8-10           Sec. 413.0513.  CONFIDENTIALITY REQUIREMENTS.
8-11     (a)  Information that is confidential under law may not be
8-12     disclosed under Section 413.0512 except:
8-13                 (1)  in a criminal proceeding;
8-14                 (2)  in a hearing conducted by or on behalf of the
8-15     commission;
8-16                 (3)  in a hearing conducted by another licensing or
8-17     regulatory authority, as provided in the interagency agreement; or
8-18                 (4)  on a finding of good cause in an administrative or
8-19     judicial proceeding involving the enforcement of this subtitle or
8-20     in a disciplinary action under this subtitle.
8-21           (b)  Confidential information developed by the commission
8-22     under Section 413.0512 is not subject to discovery or court
8-23     subpoena in any action other than:
8-24                 (1)  an action to enforce this subtitle brought by the
8-25     commission, an appropriate licensing or regulatory agency, or an
8-26     appropriate enforcement authority; or
 9-1                 (2)  a criminal proceeding.
 9-2           SECTION 1.03.  EFFECTIVE DATE.  (a)  This Act takes effect
 9-3     September 1, 2001.
 9-4           (b)  The Texas Workers' Compensation Commission shall adopt
 9-5     rules as required by Chapter 408, Labor Code, as amended by this
 9-6     Act, not later than February 1, 2002.  A doctor covered under this
 9-7     act is required to hold a certificate of registration issued under
 9-8     Section 408.023 to perform medical services under Subtitle A, Title
 9-9     5, Labor Code by the date provided by commission rules adopted to
9-10     implement this act.
9-12           SECTION 2.01.  Subchapter B, Chapter 408, Labor Code, is
9-13     amended by adding Section 408.0221 to read as follows:
9-14           Sec. 408.0221.  SELECTION OF DOCTOR WITHIN NETWORK.  (a)  The
9-15     commission shall establish a medical network advisory committee
9-16     that includes:
9-17                 (1)  Organized labor and employee representatives;
9-18                 (2)  Public employer representatives selected from the
9-19     State Office of Risk Management, University of Texas System, Texas
9-20     A&M University System, Texas Department of Transportation, Texas
9-21     Association of School Boards, Texas Municipal League and Texas
9-22     Association of Counties;
9-23                 (3)  Private sector employers and insurance carrier
9-24     representatives including the Texas Workers' Compensation Fund.
9-25                 (4)  The commission's medical advisor created under
9-26     Section 413.0511 and representatives of the medical quality panel
 10-1    created under Section 413.0512 of this Act; and
 10-2                (5)  Representatives of the Employee Retirement System,
 10-3    Comptroller of Public Accounts, Texas Department of Insurance, and
 10-4    Texas Health Care Information Council as the commission deems
 10-5    necessary.
 10-6          (b)  The commission, with the input from the medical network
 10-7    advisory committee, shall create standards for workers'
 10-8    compensation health care delivery networks authorized by this
 10-9    subchapter.
10-10          (c)  The commission shall establish regional workers'
10-11    compensation health care delivery networks, to be known as
10-12    networks, by contract.
10-13          (d)  A health care provider who participates in a network
10-14    created under this section shall be reimbursed as provided in the
10-15    contract and shall be subject to reduced regulation and
10-16    preauthorization as well as uniform billing and utilization review
10-17    requirements.
10-18          (e)  A doctor providing medical services to an employee under
10-19    this section must be on the commission's list of approved doctors.
10-20    A doctor may perform only those procedures that are within the
10-21    scope of the practice for which the doctor is licensed.
10-22          (f)  An employee may elect to participate in a network
10-23    created under this section:
10-24                (1)  at the time of hire or upon the notification of
10-25    workers' compensation coverage by the employer, concurrent with the
10-26    elections under Section 406.034; and
 11-1                (2)  an employee that elected not to participate in the
 11-2    network under subsection (f)(1), may elect to participate in the
 11-3    network no later than 14 days of the employee's date of injury, or
 11-4    at a later date with the agreement of the insurance carrier and the
 11-5    approval of the commission.
 11-6          (g)  An employee who elects to participate in the network
 11-7    shall receive:
 11-8                (1)  income benefits from the date disability begins if
 11-9    the disability lasts two weeks or longer, rather than the four
11-10    weeks as required by Section 408.082(c) of this subtitle; and
11-11                (2)  an increased maximum weekly benefit of up to 150%
11-12    of the State Average Weekly Wage for temporary income benefits,
11-13    rather than 100% as provided by Section 408.061 of this subtitle.
11-14          (h)  An employee who elects to participate in a network
11-15    established in subsection (c) shall either:
11-16                (1)  select an initial treating doctor within the
11-17    network; or
11-18                (2)  select an initial treating doctor outside of the
11-19    network if the employee has a pre-existing doctor-patient
11-20    relationship with the doctor and the doctor agrees in writing to
11-21    abide by the terms of the network contract.
11-22          (i)  An employee who selects an initial treating doctor under
11-23    subsection (h) may change treating doctors within the network in
11-24    accordance with Section 408.022 (d) and (e) of this subtitle.  An
11-25    employee that requests to change treating doctors within the
11-26    network is not subject to Section 408.022 (b) and (c) of this
 12-1    subtitle.  The employee may request to change to a treating doctor
 12-2    outside of the network with the approval of the network or by a
 12-3    decision of the commission.
 12-4          (j)  Except in an emergency, an employee who elects to
 12-5    participate in a network established in subsection (c) shall
 12-6    receive medical treatment from health care providers within the
 12-7    network.
 12-8          (k)  To resolve a dispute arising under this Subsection, an
 12-9    employee or an employee's treating doctor that requests to use a
12-10    health care provider outside of the network may request a review of
12-11    the necessity of an alternate doctor by an independent review
12-12    organization under Section 413.031(c).  A health care provider
12-13    outside of the network that is authorized to treat the employee
12-14    must agree to abide by the terms of the network contract prior to
12-15    providing any medical service under this chapter.
12-16          (l)  An employee who elects not to participate in a network
12-17    is subject to the selection and change of doctor requirements in
12-18    chapter 408, Subchapter B of this subtitle.
12-19          SECTION 2.02.  EFFECTIVE DATE.  (a)  This Act takes effect
12-20    September 1, 2001.
12-21          (b)  The Texas Workers' Compensation Commission shall adopt
12-22    rules as required by Chapter 408, Labor Code, as amended by this
12-23    Act, not later than December 1, 2001.
12-24          (c)  The Texas Workers' Compensation Commission shall convene
12-25    the first meeting of the medical network advisory committee no
12-26    later than October 1, 2001.
 13-1          (d)  The Texas Workers' Compensation Commission shall
 13-2    establish regional workers' compensation health care delivery
 13-3    networks no later than May 1, 2002.
 13-5          SECTION 3.01.  Section 409.005, Labor Code, is amended by
 13-6    adding Subsection (j) to read as follows:
 13-7          Sec. 409.005.  EMPLOYER REPORT OF INJURY; MODIFIED DUTY
 13-9          (j)  The employer shall notify the employee, treating doctor
13-10    if known, and insurance carrier of the existence or absence of
13-11    modified duty opportunities or a modified duty return-to-work
13-12    program available through the employer.  If modified duty
13-13    opportunities or a program for modified duty exists, the employer
13-14    must identify the employer's contact person, and provide other
13-15    information to assist the treating doctor and the employee to
13-16    assess return-to-work options.  The employer shall provide the
13-17    required notice as soon as possible after the injury, but no later
13-18    than the eighth day after the employee's absence from work for more
13-19    than one day due to an injury, unless the commission modifies this
13-20    notification requirement by rule.
13-21          (k)  A person commits a violation if the person fails to
13-22    comply with this section unless good cause exists.  A violation
13-23    under this subsection is a Class D administrative violation.
13-24          SECTION 3.02.  Subchapter B, Chapter 413, Labor Code, is
13-25    amended by adding a Section 413.021 to read as follows:
13-26          Sec. 413.021.  RETURN-TO-WORK COORDINATION SERVICES.
 14-1    (a)  The insurance carrier shall notify the employer of the
 14-2    availability of return-to-work coordination services.  An insurance
 14-3    carrier shall, with the agreement of a participating employer,
 14-4    provide the employer with return-to-work coordination services as
 14-5    necessary to facilitate an employee's re-integration to work.  In
 14-6    offering the services, insurance carriers and the commission shall
 14-7    target small employers and employers without return-to-work
 14-8    programs, and shall focus return-to-work efforts on workers that
 14-9    begin to receive temporary income benefits.
14-10          (b)  Return-to-work coordination services include:
14-11                (1)  job analysis to identify the physical demands of a
14-12    job;
14-13                (2)  job modification and restructuring assessments as
14-14    necessary to match job requirements with the functional capacity of
14-15    an employee; and
14-16                (3)  other reasonable services that facilitate return
14-17    to work.
14-18          (c)  The commission shall hire or secure the services of
14-19    certified rehabilitation counselors or other comparably
14-20    credentialed vocational specialists to provide training to
14-21    commission staff regarding the coordination of return-to-work
14-22    programs under this section and to assist in the evaluation and
14-23    resolution of disputes regarding return-to-work coordination
14-24    services available under this section.
14-25          (d)  The commission shall adopt rules to define the extent of
14-26    required services, minimum credentials of service providers,
 15-1    appropriate service provider fees and insurance carriers reporting
 15-2    of those fees, and other matters necessary to implement this
 15-3    section.
 15-4          (e)  The commission shall report twice annually to the
 15-5    Research and Oversight Council on Workers' Compensation regarding
 15-6    the implementation and outcome of the return to work initiatives
 15-7    required by this section.
 15-8          SECTION 3.03.  EFFECTIVE DATE.  This Act takes effect
 15-9    September 1, 2001.  The Texas Workers' Compensation Commission
15-10    shall adopt rules and implement the provisions of section two of
15-11    this Act not later than March 1, 2002.  The change in law made by
15-12    this section two of this Act expires on September 1, 2004 unless
15-13    the law is extended by action of the legislature.
15-15                            AND CERTIFICATION.
15-16          SECTION 4.01.  Section 408.026, Labor Code, is amended to
15-17    read as follows:
15-19    OPINION].  [(a)]  Except in a medical emergency, an insurance
15-20    carrier is liable for medical costs related to spinal surgery only
15-21    if[:]  the insurance carrier preauthorizes the surgery as provided
15-22    by Section 413.014 and commission rules.  [(1)  before surgery, the
15-23    employee obtains from a doctor approved by the insurance carrier or
15-24    the commission a second opinion that concurs with the treating
15-25    doctor's recommendation;]
15-26                [(2)  the insurance carrier waives the right to an
 16-1    examination or fails to request an examination before the 15th day
 16-2    after the date of the notification that surgery is recommended; or]
 16-3                [(3)  the commission determines that extenuating
 16-4    circumstances exist and orders payment for surgery.]
 16-5          [(b)  The commission shall adopt rules necessary to ensure
 16-6    that an examination required under this section is performed
 16-7    without undue delay.]
 16-8          SECTION 4.02.  Section 413.014, Labor Code, is amended to
 16-9    read as follows:
16-11    REVIEW AND CERTIFICATION OF HEALTH CARE.  (a)  The commission by
16-12    rule shall specify which health care treatments and services
16-13    require express preauthorization and concurrent review by the
16-14    insurance carrier.  Treatments and services for a medical emergency
16-15    do not require express preauthorization or concurrent review.
16-16          (b)  The commission rules adopted under this section shall
16-17    provide that preauthorization and concurrent review is required at
16-18    a minimum for:
16-19                (1)  spinal surgery, as provided by Section 408.026;
16-20                (2)  work-hardening or work-conditioning services
16-21    provided by a health care facility that is not credentialed by an
16-22    organization recognized by commission rules;
16-23                (3)  inpatient hospitalization; and
16-24                (4)  any new or investigational procedure identified by
16-25    commission rule.
16-26          (c)  The insurance carrier is not liable for those specified
 17-1    treatments and services requiring preauthorization unless
 17-2    preauthorization is sought by the claimant or health care provider
 17-3    and either obtained from the insurance carrier or ordered by the
 17-4    commission.
 17-5          (d)  Each insurance carrier shall allow health care providers
 17-6    the option to request that the insurance carrier prospectively or
 17-7    concurrently certify coverage for health care services, including
 17-8    pharmaceutical services, that do not require preauthorization and
 17-9    concurrent review.  The carrier retains the right to review health
17-10    care services and their supporting records and to contest the
17-11    certification of those services based upon:
17-12                (1)  the representations of the provider made at the
17-13    time the certification was requested;
17-14                (2)  the medical services actually provided versus
17-15    those certified; and
17-16                (3)  evidence deemed relevant to the review of
17-17    certifications as determined and set forth by commission rules.
17-18          (e)  The commission may by rule provide that an insurance
17-19    carrier is liable for payment of specified medical services within
17-20    the first 14 days following a report of injury if the health care
17-21    provider requests and receives certification of insurance coverage
17-22    and a report of injury from the employer or from the insurance
17-23    carrier.  The rules adopted by the commission may also provide that
17-24    an insurance carrier is eligible for reimbursement for medical
17-25    services paid under this subsection from the subsequent injury fund
17-26    in the event the injury is determined not to be compensable.
 18-1          SECTION 4.03.  EFFECTIVE DATE.  This Act takes effect
 18-2    September 1, 2001 and the commission shall adopt the rules required
 18-3    under this Act by April 1, 2002.
 18-5          SECTION 5.01.  Section 408.004, Labor Code, is amended to
 18-6    read as follows:
 18-7          Sec. 408.004.  Required Medical Examinations; Administrative
 18-8    Violation.  (a)  The commission may require an employee to submit
 18-9    to medical examinations to resolve any question about:
18-10                (1)  the appropriateness of the health care received by
18-11    the employee;
18-12                (2)  the impairment caused by the compensable injury;
18-13                (3)  the attainment of maximum medical improvement;
18-14    [or]
18-15                (4)  the employee's ability to return to work; or
18-16                (5)  similar issues.
18-17          (b)  [effective for dates of injury on or before September 1,
18-18    1997] The commission may require an employee to submit to a medical
18-19    examination at the request of the insurance carrier.  An
18-20    examination shall be performed by the next available doctor
18-21    appropriate for the injured employee's medical condition on the
18-22    commission designated doctor list.  The designated doctor shall
18-23    report to the commission.  The report of the designated doctor has
18-24    presumptive weight unless the great weight of the evidence is to
18-25    the contrary.  An employer may make a bona fide offer of employment
18-26    as provided by Sections 408.103(e) and 408.144(c) based on the
 19-1    designated doctor's report.[, but only after the insurance carrier
 19-2    has attempted and failed to receive the permission and concurrence
 19-3    of the employee for the examination.  The insurance carrier is
 19-4    entitled to the examination only once in a 180-day period.  A
 19-5    subsequent examination must be performed by the same doctor unless
 19-6    otherwise approved by the commission.]
 19-7          [(b)  effective for dates of injury on or after September 1,
 19-8    1997  The commission may require an employee to submit to a medical
 19-9    examination at the request of the insurance carrier, but only after
19-10    the insurance carrier has attempted and failed to receive the
19-11    permission and concurrence of the employee for the examination.
19-12    Except as otherwise provided by this subsection, the insurance
19-13    carrier is entitled to the examination only once in a 180-day
19-14    period.  The commission may adopt rules that require an employee to
19-15    submit to not more than three medical examinations in a 180-day
19-16    period under specified circumstances, including to determine
19-17    whether there has been a change in the employee's condition,
19-18    whether it is necessary to change the employee's diagnosis, and
19-19    whether treatment should be extended to another body part or
19-20    system.  The commission by rule shall adopt a system for monitoring
19-21    requests made under this subsection by insurance carriers.  That
19-22    system must ensure that good cause exists for any additional
19-23    medical examination allowed under this subsection that is not
19-24    requested by the employee.  A subsequent examination must be
19-25    performed by the same doctor unless otherwise approved by the
19-26    commission.]
 20-1          (c)  An insurance carrier may request the commission to order
 20-2    an employee to attend an examination by a doctor selected by the
 20-3    insurance carrier if the insurance carrier is not satisfied with
 20-4    the opinion rendered by a designated doctor under Subsection (b) of
 20-5    this section.  The commission shall allow the insurance carrier
 20-6    reasonable time to obtain and present the opinion of the doctor
 20-7    selected under this subsection before the commission makes a final
 20-8    decision on the merits of the issue in question.
 20-9          (d)  The insurance carrier shall pay for:
20-10                (1)  an examination required under Subsection (a) or
20-11    (b); and
20-12                (2)  the reasonable expense incident to the employee in
20-13    submitting to the examination.
20-14          (e)  An injured employee is entitled to have a doctor of the
20-15    employee's choice present at an examination required by the
20-16    commission at the request of an insurance carrier.  The insurance
20-17    carrier shall pay a fee set by the commission to the doctor
20-18    selected by the employee.  [effective for required medical
20-19    examinations scheduled to occur before January 1, 2000) If the
20-20    report of a doctor selected by an insurance carrier indicates that
20-21    the employee can return to work immediately, the commission shall
20-22    schedule a benefit review conference on the next available docket.
20-23    The insurance carrier may not suspend medical or income benefit
20-24    payments pending the benefit review conference.]
20-25          (e)  (effective for required medical examinations scheduled
20-26    to occur on or after January 1, 2000)  An employee who, without
 21-1    good cause as determined by the commission, fails or refuses to
 21-2    appear at the time scheduled for an examination under Subsection
 21-3    (a) or (b) commits a violation.  A violation under this subsection
 21-4    is a Class D administrative violation.  An employee is not entitled
 21-5    to temporary income benefits, and an insurance carrier may suspend
 21-6    the payment of temporary income benefits, during and for a period
 21-7    in which the employee fails to submit to an examination under
 21-8    Subsection (a) or (b) unless the commission determines that the
 21-9    employee had good cause for the failure to submit to the
21-10    examination.  The commission may order temporary income benefits to
21-11    be paid for the period that the commission determines the employee
21-12    has good cause.  The commission by rule shall ensure that an
21-13    employee receives reasonable notice of an examination and of the
21-14    insurance carrier's basis for suspension of payment, and that the
21-15    employee is provided a reasonable opportunity to reschedule an
21-16    examination missed by the employee for good cause.
21-17          [(f)  (effective for required medical examinations scheduled
21-18    to occur before January 1, 2000)  An employee who, without good
21-19    cause, fails or refuses to appear at the time scheduled for an
21-20    examination under Subsection (a) or (b) commits a violation.  A
21-21    violation under this subsection is a Class D administrative
21-22    violation.]
21-23          (f)  (effective for required medical examinations scheduled
21-24    to occur on or after January 1, 2000)  If the report of a
21-25    designated doctor or a doctor selected by an insurance carrier
21-26    indicates that an employee can return to work immediately or has
 22-1    reached maximum medical improvement, the insurance carrier may
 22-2    suspend or reduce the payment of temporary income benefits on the
 22-3    14th day after the date on which the insurance carrier files a
 22-4    notice of suspension with the commission as provided by this
 22-5    subsection.  The commission shall hold an expedited benefit review
 22-6    conference, by personal appearance or by telephone, not later than
 22-7    the 10th day after the date on which the commission receives the
 22-8    insurance carrier's notice of suspension.  If a benefit review
 22-9    conference is not held by the 14th day after the date on which the
22-10    commission receives the insurance carrier's notice of suspension,
22-11    an interlocutory order, effective from the date of the report
22-12    certifying maximum medical improvement, is automatically entered
22-13    for the continuation of temporary income benefits until a benefit
22-14    review conference is held, and the insurance carrier is eligible
22-15    for reimbursement for any overpayment of benefits as provided by
22-16    Chapter 410.  The commission is not required to automatically
22-17    schedule a contested case hearing as required by Section 410.025(b)
22-18    if a benefit review conference is scheduled under this subsection.
22-19    If a benefit review conference is held not later than the 14th day,
22-20    the commission may enter an interlocutory order for the
22-21    continuation of benefits, and the insurance carrier is eligible for
22-22    reimbursement for any overpayments of benefits as provided by
22-23    Chapter 410.  The commission shall adopt rules as necessary to
22-24    implement this subsection under which:
22-25                (1)  an insurance carrier is required to notify the
22-26    employee and the treating doctor of the suspension of benefits
 23-1    under this subsection by certified mail or another verifiable
 23-2    delivery method;
 23-3                (2)  the commission makes a reasonable attempt to
 23-4    obtain the treating doctor's opinion before the commission makes a
 23-5    determination regarding the entry of an interlocutory order; and
 23-6                (3)  the commission may allow abbreviated contested
 23-7    case hearings by personal appearance or telephone to consider
 23-8    issues relating to overpayment of benefits under this section.
 23-9          (f) [(g)]  (effective for dates of injury on or after
23-10    September 1, 1997)  An insurance carrier who unreasonably requests
23-11    a medical examination under Subsection (b) commits a violation.  A
23-12    violation under this subsection is a Class B administrative
23-13    violation.
23-14          SECTION 5.02.  EFFECTIVE DATE.  This Act is effective
23-15    September 1, 2001, and the change in law made by this act is
23-16    effective for a request for an examination requested on or after
23-17    January 1, 2002.
23-19          SECTION 6.01.  Section 408.028 of the Labor Code is amended
23-20    to read as follows:
23-21          Sec. 408.028.  Pharmaceutical Services.  (a)  A doctor
23-22    [health care practitioner] providing care to an employee under this
23-23    subchapter shall prescribe for the employee any necessary
23-24    prescription drugs and nonprescription medications in accordance
23-25    with:
23-26                (1)  applicable state law; and
 24-1          (b)  In establishing fee and treatment guidelines regarding
 24-2    pharmaceuticals under Chapter 413, the commission shall develop a
 24-3    formulary that requires generic pharmaceutical medications when
 24-4    authorized by the prescribing doctor.  The doctor and pharmacist
 24-5    may discuss medication options that will achieve the desired
 24-6    therapeutic results while controlling costs and reducing adverse
 24-7    impacts.
 24-8          (c)  An insurance carrier may not require an employee to use
 24-9    pharmaceutical services designated by the carrier.
24-10          SECTION 6.02.  EFFECTIVE DATE.  This Act takes effect
24-11    September 1, 2001, and the commission shall adopt rules required by
24-12    this Act by June 1, 2002.
24-13          SECTION 6.03.  Sections 413.031, 413.041, and 415.0035 of the
24-14    Labor Code, are amended to read as follows:
24-15          Sec. 413.031.  Medical Dispute Resolution.  (a)  A party,
24-16    including a health care provider or claimant, is entitled to a
24-17    review of a medical service provided or for which authorization of
24-18    payment is sought if that party [a health care provider] is:
24-19                (1)  denied payment or paid a reduced amount for the
24-20    medical service rendered;
24-21                (2)  denied authorization for the payment for the
24-22    service requested or performed if authorization is required or
24-23    allowed by [the medical policies of the] this subtitle or
24-24    commission rules; [or]
24-25                (3)  ordered by the commission [division] to refund a
24-26    payment received; or
 25-1                (4)  ordered to make a payment refused or reduced for a
 25-2    medical service rendered.
 25-3          (b)  A health care provider who submits a charge in excess of
 25-4    the fee guidelines or treatment policies is entitled to a review of
 25-5    the medical service to determine if reasonable medical
 25-6    justification exists for the deviation.
 25-7          (c)  A review of the medical necessity of a medical service
 25-8    provided or requested and denied under this chapter [section] shall
 25-9    be provided by a health care provider professional independent
25-10    review organization [if requested by the health care practitioner
25-11    or if ordered by the commission], unless the health care provider
25-12    and the insurance carrier agree to waive this requirement as
25-13    provided by commission rules.  The insurance carrier shall pay the
25-14    cost of the review unless the commission, based on the findings of
25-15    the review, determines that the health care provider has repeatedly
25-16    or unreasonably exceeded medically sound practices, in which case
25-17    the health care provider shall be ordered to pay the cost of the
25-18    review.
25-19          SECTION 6.04.  EFFECTIVE DATE.  This Act takes effect
25-20    September 1, 2001 and is effective for any request for a review of
25-21    medical services covered under this Act received by the commission
25-22    on or after January 1, 2002.
25-23          Sec. 413.041.  DISCLOSURE.  (a)  A doctor shall disclose to
25-24    the commission the health care providers in which the doctor or the
25-25    health care provider that employs the doctor, has a financial
25-26    interest as provided by the regulations adopted by the federal
 26-1    government for the Medicare program.  The commission shall require
 26-2    by rule that a doctor disclose financial interests in other health
 26-3    care providers as a condition of registration for the Approved
 26-4    Doctor List established under 408.023 and shall adopt the federal
 26-5    regulations that define financial interest.  A doctor or health
 26-6    care provider that fails to comply with this section is subject to
 26-7    penalties and sanctions as provided by this subtitle including the
 26-8    forfeiture of the right to reimbursement for services rendered
 26-9    during the period of non-compliance.  [A health care provider who
26-10    refers a workers' compensation claimant to another health care
26-11    provider in which the referring provider has more than a five
26-12    percent financial interest shall file an annual disclosure
26-13    statement with the commission as provided by commission rules and
26-14    shall disclose the interest to the insurance carrier at the time of
26-15    the referral.  The referring provider shall specify the degree of
26-16    the financial interest and shall provide other information as
26-17    required by commission rules.]
26-18          SECTION 6.05.  EFFECTIVE DATE.  This Act is effective
26-19    September 1, 2001 and the change in law by this Act applies to
26-20    financial interests and services on the date provided by commission
26-21    rule adopted to implement this Act.
26-22          SECTION 6.06.  Sections 415.0035 and 415.023 of the Labor
26-23    Code are amended to read as follows:
26-24          Sec. 415.0035.  Additional Violations by Insurance Carrier or
26-25    Health Care Provider.
26-26          (e)  An insurance carrier or health care provider commits an
 27-1    administrative violation if that person commits a violation of a
 27-2    provision of this subtitle or commission rule, or violates an order
 27-3    or decision of the commission.
 27-4          (f)  A subsequent or repeat administrative violation as
 27-5    provided by this section, after prior notice of non-compliance, is
 27-6    subject to penalty as provided by Section 415.021 of this chapter.
 27-7    Prior notice is not required if the violation was committed
 27-8    wilfully or intentionally, or the violation was of a decision or
 27-9    order of the commission.
27-10          Sec. 415.023.  Commission of Wrongful Act as Matter of
27-11    Practice; Administrative Violation.  (a)  A person who commits an
27-12    administrative violation under Section 415.001, 415.002, [or]
27-13    415.003, or 415.0035 as a matter of practice is subject to an
27-14    applicable rule adopted under Subsection (b) in addition to the
27-15    penalty assessed for the violation.
27-16          (b)  The commission may adopt rules providing for:
27-17                (1)  a reduction or denial of fees;
27-18                (2)  public or private reprimand by the commission;
27-19                (3)  suspension from practice before the commission; or
27-20                (4)  restriction, suspension, or revocation of the
27-21    right to receive reimbursement under this subtitle; or
27-22                (5)  referral and petition to the appropriate licensing
27-23    agency to restrict, suspend, or revoke the license of the violator.
27-24          SECTION 6.07.  EFFECTIVE DATE.  The change in law made by
27-25    this Act to Sections 415.0035 and 415.023 of the Labor Code is
27-26    effective September 1, 2001 and apply to any violation that occurs
 28-1    on or after the effective date of this Act.