By:  Giddings                                                     H.B. No. 3168



A BILL TO BE ENTITLED

AN ACT

relating to an alternative medical dispute resolution process for 
low-cost medical services in the Texas workers' compensation 
system.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:                        
	SECTION 1.  Section 413.031, Labor Code, is amended by 
amending Subsections (e)-(g) as follows, and the subsequent 
subsections are re-lettered accordingly:
	Sec. 413.031.  MEDICAL DISPUTE RESOLUTION.  (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.
	(f)  The commission by rule shall specify the appropriate 
dispute resolution process for disputes in which a claimant has 
paid for medical services and seeks reimbursement.
	(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.  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 3.  The change in law made by this Act applies to a 
request for medical dispute resolution filed with the commission on 
or after the effective date of this Act.