78R7362 T
By: Martinez Fischer H.B. No. 3285
A BILL TO BE ENTITLED
AN ACT
relating to the regulation of Reimbursement Policies and Guidelines
and Treatment Guidelines for medical care in the provision of
workers' compensation benefits by the Texas Workers' Compensation
Commission.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 413, Section 413.011 is
amended to read as follows:
Sec. 413.011. REIMBURSEMENT POLICIES AND GUIDELINES;
TREATMENT GUIDELINES. (a) The commission shall use health care
reimbursement policies and guidelines that reflect the
standardized reimbursement structures found in other health care
delivery systems with minimal modifications to those reimbursement
methodologies as necessary to meet occupational injury
requirements. To achieve standardization, the commission shall
adopt the most current medical and payment policies used by the
federal Centers for Medicare and Medicaid Services as they relate
to coding, billing, and reporting, and may modify those policies
[reimbursement methodologies, models, and values or weights used by
the federal Health Care Financing Administration, including
applicable payment policies relating to coding, billing, and
reporting, and may modify documentation requirements] as necessary
to meet the requirements of Section 413.053.
(b) Guidelines for medical services fees must be fair and
reasonable and designed to ensure prompt access to quality medical
care.
(c) (1) To establish a baseline medical fee guideline, the
commission shall determine and adopt separate conversion factors
for Surgery; Radiology; Pathology; Anesthesia; General Medicine;
Physical Medicine; and Evaluation and Management by calculating the
average commercial reimbursement rate for providers using the
actual claims data study from the 2001 "Medicare Physician Fees
Compared to Average Private Rates" as commissioned by the Medicare
Payment Advisory Commission. To the commercial reimbursement rate,
the commission shall apply successively the Medicare Economic Index
updates for each year between the 2001 Medicare Payment Advisory
Commission study and September 1, 2003. The commission shall then
add no less than 20 percent to compensate for the difference in the
administrative burden to treat patients in commercial plans versus
those in the workers' compensation system.
(2) After the baseline medical fee guideline in this
subsection is established, starting on September 1, 2004, and each
September 1st thereafter, the commission shall adopt and apply by
rule the Medicare Economic Index updates to the providers' medical
fee guideline.
(d) [(b) In determining the appropriate fees, the
commission shall also develop conversion factors or other payment
adjustment factors taking into account economic indicators in
health care and the requirements of Subsection (d). The commission
shall also provide for reasonable fees for the evaluation and
management of care as required by Section 408.025(c) and commission
rules.] This section does not adopt the Medicare fee schedule, and
the commission shall not adopt conversion factors or other payment
adjustment factors based [solely] on those factors as developed by
the federal Centers for Medicare and Medicaid Services [Health Care
Financing Administration].
(e) [(c)] This section may not be interpreted in a manner
that would discriminate in the amount or method of payment or
reimbursement for services in a manner prohibited by Section 3(d),
Article 21.52, Insurance Code, or as restricting the ability of
chiropractors to serve as treating doctors as authorized by this
subtitle. The commission shall also develop guidelines relating to
fees charged or paid for providing expert testimony relating to an
issue arising under this subtitle.
[(d) Guidelines for medical services fees must be fair and
reasonable and designed to ensure the quality of medical care and to
achieve effective medical cost control. The guidelines may not
provide for payment of a fee in excess of the fee charged for
similar treatment of an injured individual of an equivalent
standard of living and paid by that individual or by someone acting
on that individual's behalf. The commission shall consider the
increased security of payment afforded by this subtitle in
establishing the fee guidelines.]
(e) The commission by rule may adopt treatment guidelines,
including return-to-work guidelines. If adopted, treatment
guidelines adopted must be nationally recognized, scientifically
valid, and outcome-based and designed to reduce excessive or
inappropriate medical care while safeguarding necessary medical
care.
(f) The commission by rule may establish medical policies or
treatment guidelines relating to necessary treatments for
injuries.
(g) Any medical policies or guidelines adopted by the
commission must be:
(1) designed to ensure the quality of medical care and
to achieve effective medical cost control;
(2) designed to enhance a timely and appropriate
return to work; and
(3) consistent with Sections 413.013, 413.020,
413.052, and 413.053.
SECTION 2. No later than September 1, 2004, the Research and
Oversight Council shall present to its board of directors
recommendations regarding how it, or an outside consultant, can
most efficiently and economically measure the administrative
burdens under Subsection (c) of Section 413.011. These
recommendations will not be binding and the methodology they
contain must be free of bias or input by any group that participates
in workers' compensation system and that of the Texas Workers'
Compensation Commission.
SECTION 3. EFFECTIVE DATE. 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.