By: Solomons H.B. No. 473

A BILL TO BE ENTITLED

AN ACT

relating to the application of certain fee guidelines to health care provided under the workers' compensation system.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 413.011, Labor Code, is amended by amending Subsection (d) and adding Subsections (d-1) through (d-6) to read as follows:

(d) Fee guidelines 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 commissioner shall consider the increased security of payment afforded by this subtitle in establishing the fee guidelines.

(d-1) Notwithstanding Subsections (b) through (d) and Section 413.016 [or any other provision of this title], an insurance carrier may pay fees to a health care provider that are inconsistent with the fee guidelines adopted by the division if the insurance carrier, or a network under Chapter 1305, Insurance Code, arranging out-of-network services under Section 1305.006, Insurance Code, has a contract with the health care provider and that contract includes a specific fee schedule. An insurance carrier or the carrier's authorized agent may use an informal or voluntary network, as those terms are defined by Section 413.0115, to obtain a contractual agreement that provides for fees different from the fees authorized under the division's fee guidelines. If a carrier or the carrier's authorized agent chooses to use an informal or voluntary network to obtain a contractual fee arrangement, there must be a contractual arrangement between:

(1) the carrier or authorized agent and the informal or voluntary network that authorizes the network to contract with health care providers on the carrier's behalf; and

(2) the informal or voluntary network and the health care provider that includes a specific fee schedule and complies with the notice requirements established under Subsection (d-2).

(d-2) An informal or voluntary network, or the carrier or the carrier's authorized agent, as appropriate, shall notify each health care provider of any person that is given access to the network's fee arrangements with that health care provider within the time and according to the manner provided by commissioner rule.

(d-3) An insurance carrier shall provide copies of each contract described by Subsection (d-1) to the division on the request of the division. Information included in a contract under Subsection (d-1) is confidential and is not subject to disclosure under Chapter 552, Government Code. For medical fee disputes that arise regarding non-network and out-of-network care, the division may request that copies of each contract under which fees are being paid be submitted to the division for review. Notwithstanding Subsection (d-1) or Section 1305.153, Insurance Code, the insurance carrier may be required to pay fees in accordance with the division's fee guidelines if the contract:

(1) is not provided in a timely manner to the division on the division's request;

(2) does not include a specific fee schedule consistent with Subsection (d-1); and

(3) does not:

(A) clearly state that the contractual fee arrangement is between the health care provider and the named insurance carrier or the named insurance carrier's authorized agent; or

(B) comply with the notice requirements under Subsection (d-2).

(d-4) Notwithstanding this section or any other provision of this title, an insurance carrier, an insurance carrier's authorized agent, or a network certified under Chapter 1305, Insurance Code, arranging for non-network services or out-of-network services under Section 1305.006, Insurance Code, may continue to contract with a health care provider to secure health care for an injured employee for fees that exceed the fees adopted by the division under this section.

(d-5) The commissioner and the commissioner of insurance may adopt rules as necessary to implement this section.

(d-6) Subsections (d-1) through (d-3) and this subsection expire January 1, 2011.

SECTION 2. Subchapter B, Chapter 413, Labor Code, is amended by adding Section 413.0115 to read as follows:

Sec. 413.0115. REQUIREMENTS FOR CERTAIN VOLUNTARY OR INFORMAL NETWORKS. (a) In this section:

(1) "Informal network" means a health care provider network described by Section 413.011(d-1) that:

(A) is established under a contract between an insurance carrier and health care providers; and

(B) includes a specific fee schedule.

(2) "Voluntary network" means a voluntary workers' compensation health care delivery network established by an insurance carrier under former Section 408.0223, as that section existed before repeal by Chapter 265, Acts of the 79th Legislature, Regular Session, 2005.

(b) Not later than January 1, 2011, each informal network or voluntary network must be certified as a workers' compensation health care network under Chapter 1305, Insurance Code.

(c) Effective September 1, 2007, each informal network and voluntary network must provide the following information to the division:

(1) an executive contact for official correspondence for the network;

(2) a toll-free telephone number by which a health care provider may contact the informal network or voluntary network;

(3) a list of each insurance carrier with whom the network contracts; and

(4) a list of each entity associated with the network working on behalf of the insurance carrier, including contact information for each entity.

(d) Each informal network and voluntary network shall report any changes to the information provided under Subsection (c) to the division not later than the 30th day after the effective date of the change.

SECTION 3. (a) Section 413.011(d-4), Labor Code, as added by this Act, takes effect January 1, 2011.

(b) Except as provided by Subsection (a) of this section, this Act takes effect September 1, 2007.