By: Giddings H.B. No. 3168
A BILL TO BE ENTITLED
AN ACT
relating to determination of workers' compensation benefits and to
dispute resolution regarding those benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 413.031, Labor Code, is amended by
amending Subsections (e) and (g)-(l) and adding Subsection (m) to
read as follows:
(e) Except as provided by Subsection (d), (f), or (g), a
review of the medical necessity of a health care service provided
under this chapter or Chapter 408 shall be conducted by an
independent review organization under Article 21.58C, Insurance
Code, in the same manner as reviews of utilization review decisions
by health maintenance organizations. It is a defense for the
insurance carrier if the carrier timely complies with the decision
of the independent review organization.
(g) The commission by rule may specify an alternate dispute
resolution process for medical services costing less than the cost
of a review of medical necessity by an independent review
organization. The cost of a review under this process shall be paid
by the nonprevailing party.
(h) In performing a review of medical necessity under
Subsection (d) or (e), an independent review organization may
request that the commission order an examination by a designated
doctor under Chapter 408.
(i) [(h)] The insurance carrier shall pay the cost of the
review if the dispute arises in connection with a request for health
care services that require preauthorization under Section 413.014
or commission rules under that section.
(j) [(i)] Except as provided by Subsection (i) [(h)], the
cost of the review shall be paid by the nonprevailing party.
(k) [(j)] Notwithstanding Subsections [(h) and] (i) and
(j), an employee may not be required to pay any portion of the cost
of a review.
(l) [(k)] Except as provided by Subsection (m) [(l)], a
party to a medical dispute that remains unresolved after a review of
the medical service under this section is entitled to a hearing.
The hearing shall be conducted by the State Office of
Administrative Hearings within 90 days of receipt of a request for a
hearing in the manner provided for a contested case under Chapter
2001, Government Code (the administrative procedure law). A party
who has exhausted the party's administrative remedies under this
subtitle and who is aggrieved by a final decision of the State
Office of Administrative Hearings may seek judicial review of the
decision. Judicial review under this subsection shall be conducted
in the manner provided for judicial review of contested cases under
Subchapter G, Chapter 2001, Government Code.
(m) [(l)] A party to a medical dispute regarding spinal
surgery that remains unresolved after a review by an independent
review organization as provided by Subsections (d) and (e) is
entitled to dispute resolution as provided by Chapter 410.
SECTION 2. Section 408.123, Labor Code, is amended by
adding Subsections (d), (e), (f), and (g) to read as follows:
(d) Except as provided in Subsections (e), (f), and (g), the
first valid certification of maximum medical improvement and the
first valid assignment of impairment rating to an employee are
final if the certification of maximum medical improvement and/or
the assigned impairment rating is not disputed within 90 days after
written notification of the maximum medical improvement and/or
assignment of impairment rating is provided to the claimant and the
carrier by verifiable means.
(e) The first certification of maximum medical improvement
and/or impairment rating may be disputed after the 90-day period
if:
(1) there is compelling medical evidence establishing
the following:
(A) a significant error on the part of the
certifying doctor in applying the appropriate American Medical
Association Guides and/or calculating the impairment rating;
(B) a clear misdiagnosis or a previously
undiagnosed medical condition; or
(C) prior improper or inadequate treatment of the
injury which would render the certification of maximum medical
improvement or impairment rating invalid; or
(2) there are other compelling circumstances as
established by commission rule.
(f) If an employee has not been certified as having reached
maximum medical improvement before the expiration of 104 weeks from
the date on which income benefits begin to accrue or the expiration
of the date of any extension under Section 408.104, the impairment
rating assigned after the end of the 104 weeks or after the end of
the extended period under Section 408.104 is final if the
impairment rating is not disputed within 90 days after written
notification of the maximum medical improvement and/or assignment
of impairment rating is provided to the claimant and the carrier by
verifiable means.
(g) If a disputed certification of maximum medical
improvement or assignment of impairment rating is finally modified,
overturned, or withdrawn, the first subsequent certification and
assignment becomes final if it is not disputed within 90 days after
written notification of maximum medical improvement and/or
assignment of impairment rating is provided to the claimant and the
carrier by verifiable means.
SECTION 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2003.
SECTION 4. The change in law made by this Act applies to a
request for medical dispute resolution filed with the Texas
Workers' Compensation Commission on or after the effective date of
this Act.