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A BILL TO BE ENTITLED
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AN ACT
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relating to billing practices for certain health care facilities |
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and providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 324.001, Health and Safety Code, is |
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amended by adding Subdivision (8) to read as follows: |
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(8) "Preferred provider" means a facility that |
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contracts to provide medical care or health care to participants or |
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beneficiaries of a health plan in accordance with agreed |
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reimbursement rates. |
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SECTION 2. Section 324.101, Health and Safety Code, is |
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amended by amending Subsections (e) and (f) and adding Subsections |
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(f-1), (f-2), (f-3), (f-4), (f-5), and (f-6) to read as follows: |
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(e) A facility shall provide to the consumer at the |
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consumer's request an itemized statement of the billed charges |
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[services] if the consumer requests the statement not later than |
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the first anniversary of the date the person is discharged from the |
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facility. The facility shall provide the statement to the consumer |
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not later than the 10th business day after the date on which the |
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statement is requested. The facility may provide the consumer with |
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an electronic copy of the itemized statement. |
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(f) If the billed charges exceed $10,000, the [A] facility |
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shall provide an itemized statement of the billed charges |
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[services] to a third-party payor who is actually or potentially |
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responsible for paying all or part of the billed charges for |
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providing services [provided] to a patient [and who has received a
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claim for payment of those services.
To be entitled to receive a
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statement, the third-party payor must request the statement from
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the facility and must have received a claim for payment. The
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request must be made not later than one year after the date on which
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the payor received the claim for payment]. The facility shall |
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provide the statement to the payor with the facility's claim for |
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payment. |
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(f-1) A third-party payor may request an itemized statement |
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for billed charges of $10,000 or less. |
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(f-2) A third-party payor may request additional |
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information, including medical records and operative reports, |
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relating to a claim that has been submitted for payment to the |
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third-party payor. |
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(f-3) The facility shall provide the itemized statement |
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requested under Subsection (f-1) or the information requested under |
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Subsection (f-2) as soon as practicable. The days between the date |
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a third-party payor requests the itemized statement or additional |
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information from the facility and the date the payor receives the |
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itemized statement or information may not be counted in a payment |
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period established by statute or under contract. |
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(f-4) The facility may provide the third-party payor with an |
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electronic copy of an itemized statement under this section [not
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later than the 30th day after the date on which the payor requests
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the statement]. |
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(f-5) If a third-party payor receives a claim for payment of |
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part [but not all] of the billed charges [services], the |
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third-party payor is entitled to [may request] an itemized |
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statement of only the billed charges [services] for which payment |
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is claimed or to which any deduction or copayment applies. |
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(f-6) A third-party payor that requests an itemized |
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statement under Subsection (f-1) or additional information under |
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Subsection (f-2) must have evidence sufficient to prove the date |
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the payor made the request, which may include a certified mail |
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receipt or an electronic date stamp. Unless rebutted by sufficient |
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evidence provided by a facility, the date the payor receives the |
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itemized statement or additional information, as shown in the |
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payor's records, is presumed to be the date of receipt for purposes |
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of Subsection (f-3). |
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SECTION 3. Section 324.103, Health and Safety Code, is |
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amended to read as follows: |
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Sec. 324.103. [CONSUMER] WAIVER PROHIBITED. The |
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provisions of this chapter may not be waived, voided, or nullified |
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by a contract or an agreement between a facility and a consumer or |
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third-party payor. |
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SECTION 4. Subchapter C, Chapter 324, Health and Safety |
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Code, is amended by adding Sections 324.104, 324.105, 324.106, and |
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324.107 to read as follows: |
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Sec. 324.104. CLAIM FOR PAYMENT FROM PREFERRED PROVIDER. |
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(a) A preferred provider that directly or through its agent or |
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assignee asserts that a claim for payment of a medical or health |
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care service or supply provided to a consumer, including a claim for |
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payment of the amount due for a disallowed discount on the service |
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or supply provided, has not been timely or accurately paid shall |
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provide written notification of the nonpayment or inaccuracy to the |
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third-party payor not later than the first anniversary of the |
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earlier of the date the preferred provider received payment from |
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the payor or the date that payment was due. A preferred provider or |
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agent that fails to provide the notification before that date is |
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barred from asserting the claim of nonpayment or inaccuracy. The |
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notice required by this subsection does not affect a statute of |
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limitations applicable to a claim. |
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(b) If a patient is admitted to a preferred provider for |
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more than 30 days, the preferred provider on request of a |
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third-party payor shall provide an interim statement of the |
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facility's billed charges to the third-party payor not later than |
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the 10th day after the date the third-party payor submits the |
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request. |
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Sec. 324.105. OVERPAYMENT AND REIMBURSEMENT. (a) A |
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third-party payor may recover an overpayment to a preferred |
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provider if: |
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(1) not later than the 180th day after the date the |
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provider receives the payment, the payor provides written notice of |
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the overpayment to the provider that includes the basis and |
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specific reasons for the request for recovery of funds; and |
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(2) the provider does not make arrangements for |
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repayment of the requested funds on or before the 45th day after the |
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date the provider receives the notice. |
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(b) A third-party payor that fails to provide notice of |
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overpayment by the 180th day after the date the preferred provider |
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receives a payment on a claim is barred from recovering an |
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overpayment on that claim. |
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(c) If a preferred provider disagrees with a request for |
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recovery of an overpayment, the third-party payor shall allow the |
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provider an opportunity to appeal, and the payor may not attempt to |
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recover the overpayment until all appeal rights are exhausted. |
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(d) A preferred provider that fails to make a reimbursement |
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required by this section shall pay, in addition to the |
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reimbursement, a late penalty in an amount equal to 10 percent of |
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the amount of the required reimbursement. |
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Sec. 324.106. APPLICABILITY TO ENTITIES CONTRACTING WITH |
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PREFERRED PROVIDER OR THIRD-PARTY PAYOR. This subchapter applies |
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to a person with whom: |
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(1) a preferred provider contracts to submit or |
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collect a claim for payment; or |
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(2) a third-party payor contracts to process or pay a |
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claim for payment by a preferred provider. |
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Sec. 324.107. APPLICABILITY OF OTHER LAW. If a provision of |
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this chapter and a provision of Chapter 1301, Insurance Code, apply |
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to the same person, conduct, or circumstance, Chapter 1301, |
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Insurance Code, controls. |
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SECTION 5. The changes in law made by this Act to Chapter |
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324, Health and Safety Code, apply only to services or supplies |
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provided by a health care facility to a consumer on or after the |
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effective date of this Act. Services or supplies provided before |
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the effective date of this Act are governed by the law in effect |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2009. |