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A BILL TO BE ENTITLED
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AN ACT
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relating to the provision of health care services to an employee who |
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sustains a compensable injury. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 408.0042(d), Labor Code, is amended to |
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read as follows: |
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(d) Any treatment for an injury or diagnosis that is not |
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accepted by the insurance carrier under Subsection (c) as |
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compensable at the time of the medical examination under Subsection |
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(a) must be preauthorized before treatment is rendered. If the |
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insurance carrier preauthorizes treatment and treatment is |
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rendered, the insurance carrier may not deny payment based on |
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compensability. If the insurance carrier denies preauthorization |
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because the treatment is for an injury or diagnosis unrelated to the |
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compensable injury, the injured employee may seek a prompt |
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evaluation by an appropriate health care provider and the injured |
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employee or affected health care provider may file an extent of |
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injury dispute. A dispute under this subsection must be heard not |
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later than the seventh day after the date preauthorization is |
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denied. |
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SECTION 2. Section 408.0231(b), Labor Code, is amended to |
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read as follows: |
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(b) The commissioner by rule shall establish criteria for: |
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(1) deleting or suspending a doctor from the list of |
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approved doctors; |
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(2) imposing sanctions on a doctor or an insurance |
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carrier as provided by this section; |
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(3) monitoring of utilization review agents, as |
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provided by a memorandum of understanding between the division and |
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the Texas Department of Insurance; and |
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(4) authorizing increased or reduced utilization |
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review and preauthorization controls on a doctor, as provided by a |
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memorandum of understanding between the commissioner and the |
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commissioner of insurance. |
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SECTION 3. Section 408.027(a), Labor Code, is amended to |
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read as follows: |
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(a) A health care provider shall submit a claim for payment |
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to the insurance carrier not later than the 180th [95th] day after |
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the date on which the health care services are provided to the |
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injured employee. Failure by the health care provider to timely |
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submit a claim for payment constitutes a forfeiture of the |
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provider's right to reimbursement for that claim for payment. |
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SECTION 4. Section 408.0271(a), Labor Code, is amended to |
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read as follows: |
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(a) If the health care services provided to an injured |
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employee are determined by the insurance carrier to be |
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inappropriate, not later than the 180th day after the date of the |
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insurance carrier's receipt of the claim, the insurance carrier |
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shall: |
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(1) notify the health care provider in writing of the |
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carrier's decision; and |
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(2) demand a refund by the health care provider of the |
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portion of payment on the claim that was received by the health care |
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provider for the inappropriate services. |
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SECTION 5. Section 413.014(b), Labor Code, is amended to |
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read as follows: |
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(b) The commissioner by rule shall specify which health care |
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treatments and services require express preauthorization or |
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concurrent review by the insurance carrier. Treatments and |
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services for a medical emergency or that fall within treatment |
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guidelines adopted under Section 413.011(e) do not require express |
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preauthorization. |
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SECTION 6. Section 413.016, Labor Code, is amended by |
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adding Subsection (c) to read as follows: |
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(c) A health care provider does not commit a violation and |
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is not subject to an administrative penalty under Section |
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415.003(4) solely on the basis that the provider has billed the |
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provider's usual charges for the service provided. |
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SECTION 7. Section 413.031(d), Labor Code, is amended to |
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read as follows: |
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(d) A review of the medical necessity of a health care |
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service requiring preauthorization under Section 413.014 or |
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commissioner rules under that section or Section 413.011(g) shall |
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be conducted by an independent review organization under Chapter |
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4202 [Article 21.58C], Insurance Code, in the same manner as |
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reviews of utilization review decisions by health maintenance |
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organizations. [It is a defense for the insurance carrier if the
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carrier timely complies with the decision of the independent review
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organization.] |
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SECTION 8. Section 408.024, Labor Code, is repealed. |
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SECTION 9. The change in law made by this Act applies only |
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to a claim for workers' compensation benefits based on a |
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compensable injury that occurs on or after the effective date of |
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this Act. A claim based on a compensable injury that occurs before |
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that date is governed by the law in effect on the date that the |
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compensable injury occurred, and the former law is continued in |
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effect for that purpose. |
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SECTION 10. This Act takes effect September 1, 2007. |