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A BILL TO BE ENTITLED
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AN ACT
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relating to doctor licensing requirements for peer review, |
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utilization, and retrospective review of medical decisions |
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regarding workers' compensation claims. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 401.011, Labor Code, is amended by |
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adding Subdivisions (12-a), (38-a), (42-b), and (42-c) and amending |
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Subdivision (42-a) to read as follows: |
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(12-a) "Credentialing" has the meaning assigned by |
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Chapter 1305, Insurance Code. |
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(38-a) "Retrospective review" has the meaning |
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assigned by Chapter 1305, Insurance Code. |
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(42-a) "Utilization review" has the meaning assigned |
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by Chapter 4201, Insurance Code. |
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(42-b) "Utilization review agent" has the meaning |
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assigned by Chapter 4201, Insurance Code. |
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(42-c) "Violation" means an administrative violation |
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subject to penalties and sanctions as provided by this subtitle. |
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SECTION 2. Section 408.023(h), Labor Code, is amended to |
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read as follows: |
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(h) Notwithstanding Section 4201.152 [4(h), Article
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21.58A], Insurance Code, a utilization review agent or an insurance |
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carrier that uses doctors to perform reviews of health care |
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services provided under this subtitle, including utilization |
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review and retrospective review, may only use doctors licensed [by
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another state to perform the reviews, but the reviews must be
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performed under the direction of a doctor licensed] to practice in |
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this state. |
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SECTION 3. Section 408.0231(e), Labor Code, is amended to |
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read as follows: |
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(e) The commissioner shall act on a recommendation by the |
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medical advisor selected under Section 413.0511 and, after notice |
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and the opportunity for a hearing, may impose sanctions under this |
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section on a doctor or an insurance carrier or may recommend action |
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regarding a utilization review agent. The commissioner and the |
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commissioner of insurance shall enter into a memorandum of |
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understanding to coordinate the regulation of insurance carriers |
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and utilization review agents as necessary to ensure: |
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(1) compliance with applicable regulations; and |
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(2) that appropriate health care decisions are reached |
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under this subtitle and under Chapter 4201 [Article 21.58A], |
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Insurance Code. |
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SECTION 4. Sections 1305.004(a)(12), (17), (27), and (28), |
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Insurance Code, are amended to read as follows: |
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(12) "Life-threatening" has the meaning assigned by |
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Chapter 4201 [Section 2, Article 21.58A]. |
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(17) "Nurse" has the meaning assigned by Chapter 4201 |
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[Section 2, Article 21.58A]. |
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(27) "Utilization review" has the meaning assigned by |
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Chapter 4201 [Section 2, Article 21.58A]. |
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(28) "Utilization review agent" has the meaning |
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assigned by Chapter 4201 [Article 21.58A]. |
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SECTION 5. Section 1305.154(c), Insurance Code, is amended |
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to read as follows: |
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(c) A network's contract with a carrier must include: |
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(1) a description of the functions that the carrier |
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delegates to the network, consistent with the requirements of |
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Subsection (b), and the reporting requirements for each function; |
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(2) a statement that the network and any management |
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contractor or third party to which the network delegates a function |
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will perform all delegated functions in full compliance with all |
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requirements of this chapter, the Texas Workers' Compensation Act, |
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and rules of the commissioner or the commissioner of workers' |
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compensation; |
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(3) a provision that the contract: |
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(A) may not be terminated without cause by either |
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party without 90 days' prior written notice; and |
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(B) must be terminated immediately if cause |
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exists; |
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(4) a hold-harmless provision stating that the |
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network, a management contractor, a third party to which the |
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network delegates a function, and the network's contracted |
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providers are prohibited from billing or attempting to collect any |
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amounts from employees for health care services under any |
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circumstances, including the insolvency of the carrier or the |
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network, except as provided by Section 1305.451(b)(6); |
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(5) a statement that the carrier retains ultimate |
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responsibility for ensuring that all delegated functions and all |
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management contractor functions are performed in accordance with |
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applicable statutes and rules and that the contract may not be |
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construed to limit in any way the carrier's responsibility, |
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including financial responsibility, to comply with all statutory |
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and regulatory requirements; |
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(6) a statement that the network's role is to provide |
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the services described under Subsection (b) as well as any other |
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services or functions delegated by the carrier, including functions |
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delegated to a management contractor, subject to the carrier's |
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oversight and monitoring of the network's performance; |
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(7) a requirement that the network provide the |
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carrier, at least monthly and in a form usable for audit purposes, |
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the data necessary for the carrier to comply with reporting |
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requirements of the department and the division of workers' |
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compensation with respect to any services provided under the |
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contract, as determined by commissioner rules; |
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(8) a requirement that the carrier, the network, any |
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management contractor, and any third party to which the network |
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delegates a function comply with the data reporting requirements of |
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the Texas Workers' Compensation Act and rules of the commissioner |
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of workers' compensation; |
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(9) a contingency plan under which the carrier would, |
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in the event of termination of the contract or a failure to perform, |
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reassume one or more functions of the network under the contract, |
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including functions related to: |
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(A) payments to providers and notification to |
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employees; |
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(B) quality of care; |
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(C) utilization review; |
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(D) retrospective review; and |
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(E) continuity of care, including a plan for |
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identifying and transitioning employees to new providers; |
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(10) a provision that requires that any agreement by |
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which the network delegates any function to a management contractor |
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or any third party be in writing, and that such an agreement require |
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the delegated third party or management contractor to be subject to |
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all the requirements of this subchapter; |
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(11) a provision that requires the network to provide |
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to the department the license number of a management contractor or |
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any delegated third party who performs a function that requires a |
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license as a utilization review agent under Chapter 4201 [Article
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21.58A] or any other license under this code or another insurance |
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law of this state; |
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(12) an acknowledgment that: |
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(A) any management contractor or third party to |
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whom the network delegates a function must perform in compliance |
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with this chapter and other applicable statutes and rules, and that |
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the management contractor or third party is subject to the |
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carrier's and the network's oversight and monitoring of its |
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performance; and |
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(B) if the management contractor or the third |
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party fails to meet monitoring standards established to ensure that |
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functions delegated to the management contractor or the third party |
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under the delegation contract are in full compliance with all |
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statutory and regulatory requirements, the carrier or the network |
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may cancel the delegation of one or more delegated functions; |
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(13) a requirement that the network and any management |
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contractor or third party to which the network delegates a function |
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provide all necessary information to allow the carrier to provide |
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information to employees as required by Section 1305.451; and |
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(14) a provision that requires the network, in |
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contracting with a third party directly or through another third |
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party, to require the third party to permit the commissioner to |
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examine at any time any information the commissioner believes is |
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relevant to the third party's financial condition or the ability of |
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the network to meet the network's responsibilities in connection |
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with any function the third party performs or has been delegated. |
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SECTION 6. Section 1305.351, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsection (d) to read as |
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follows: |
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(a) The requirements of Chapter 4201 [Article 21.58A] apply |
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to utilization review conducted in relation to claims in a workers' |
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compensation health care network. In the event of a conflict |
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between Chapter 4201 [Article 21.58A] and this chapter, this |
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chapter controls. |
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(d) Notwithstanding Section 4201.152, a utilization review |
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agent or an insurance carrier that uses doctors to perform reviews |
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of health care services provided under this chapter, including |
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utilization review and retrospective review, or peer reviews under |
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Section 408.0231(g), Labor Code, may only use doctors licensed to |
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practice in this state. |
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SECTION 7. (a) Sections 4201.054(a) and (d), Insurance |
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Code, as effective April 1, 2007, are amended to conform to Section |
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6.072, Chapter 265, Acts of the 79th Legislature, Regular Session, |
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2005, to read as follows: |
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(a) Except as provided by this section, this chapter applies |
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to utilization review of a health care service provided to a person |
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eligible for workers' compensation medical benefits under Title 5, |
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Labor Code. The commissioner of workers' compensation shall |
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regulate as provided by this chapter a person who performs |
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utilization review of a medical benefit provided under Title 5 |
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[Chapter 408], Labor Code. |
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(d) The commissioner of workers' compensation [and the
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Texas Workers' Compensation Commission] may adopt rules [and enter
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into memoranda of understanding] as necessary to implement this |
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section. |
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(b) Section 4201.054(b), Insurance Code, is repealed to |
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conform to Section 6.072, Chapter 265, Acts of the 79th |
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Legislature, Regular Session, 2005. |
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(c) Section 6.072, Chapter 265, Acts of the 79th |
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Legislature, Regular Session, 2005, which amended former |
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Subsection (c), Section 14, Article 21.58A, Insurance Code, is |
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repealed. |
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SECTION 8. (a) Section 4201.207(b), Insurance Code, as |
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effective April 1, 2007, is amended to conform to Section 6.071, |
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Chapter 265, Acts of the 79th Legislature, Regular Session, 2005, |
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to read as follows: |
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(b) A health care provider's charges for providing medical |
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information to a utilization review agent may not: |
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(1) exceed the cost of copying records regarding a |
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workers' compensation claim as set by rules adopted by the |
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commissioner of workers' compensation [Texas Workers' Compensation
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Commission]; or |
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(2) include any costs otherwise recouped as part of |
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the charges for health care. |
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(b) Section 6.071, Chapter 265, Acts of the 79th |
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Legislature, Regular Session, 2005, which amended former |
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Subsection (l), Section 4, Article 21.58A, Insurance Code, is |
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repealed. |
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SECTION 9. To the extent of any conflict, this Act prevails |
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over another Act of the 80th Legislature, Regular Session, 2007, |
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relating to nonsubstantive additions to and corrections in enacted |
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codes. |
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SECTION 10. The change in law made by this Act applies only |
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to a review provided under a claim for workers' compensation |
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benefits that is conducted on or after the effective date of this |
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Act. A review that is conducted before that date is governed by the |
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law in effect on the date that the review was conducted, and the |
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former law is continued in effect for that purpose. |
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SECTION 11. This Act takes effect September 1, 2007. |
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* * * * * |