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.
1-5 ARTICLE 1. AUTHORIZED DOCTORS; MEDICAL REVIEW
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:
5-26 Sec. 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH
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.
9-11 ARTICLE 2. MEDICAL NETWORK PARTICIPATION OPTION
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.
13-4 ARTICLE 3. RETURN TO WORK REPORTING AND SERVICES.
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
13-8 PROGRAM NOTICE; ADMINISTRATIVE VIOLATION.
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.
15-14 ARTICLE 4. PREAUTHORIZATION, CONCURRENT REVIEW
15-15 AND CERTIFICATION.
15-16 SECTION 4.01. Section 408.026, Labor Code, is amended to
15-17 read as follows:
15-18 Sec. 408.026. SPINAL SURGERY PREAUTHORIZATION [SECOND
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:
16-10 Sec. 413.014. PREAUTHORIZATION REQUIREMENTS; CONCURRENT
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.
18-4 ARTICLE 5. REQUIRED MEDICAL EXAMINATIONS.
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.
23-18 ARTICLE 6. MEDICAL BENEFIT REGULATION; DISPUTE RESOLUTION
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.