81R32396 E

By: Smithee H.B. No. 4183

Substitute the following for H.B. No. 4183:

By: Thompson C.S.H.B. No. 4183

A BILL TO BE ENTITLED

AN ACT

relating to billing practices for certain health care facilities and providers.

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

SECTION 1. Section 324.001, Health and Safety Code, is amended by adding Subdivision (8) to read as follows:

(8) "Preferred provider" means a facility that contracts to provide medical care or health care to participants or beneficiaries of a health plan in accordance with agreed reimbursement rates.

SECTION 2. Section 324.101, Health and Safety Code, is amended by amending Subsections (e) and (f) and adding Subsections (f-1), (f-2), (f-3), (f-4), (f-5), and (f-6) to read as follows:

(e) A facility shall provide to the consumer at the consumer's request an itemized statement of the billed charges [services] if the consumer requests the statement not later than the first anniversary of the date the person is discharged from the facility. The facility shall provide the statement to the consumer not later than the 10th business day after the date on which the statement is requested. The facility may provide the consumer with an electronic copy of the itemized statement.

(f) If the billed charges exceed $10,000, the [A] facility shall provide an itemized statement of the billed charges [services] to a third-party payor who is actually or potentially responsible for paying all or part of the billed charges for providing services [provided] to a patient [and who has received a claim for payment of those services. To be entitled to receive a statement, the third-party payor must request the statement from the facility and must have received a claim for payment. The request must be made not later than one year after the date on which the payor received the claim for payment]. The facility shall provide the statement to the payor with the facility's claim for payment.

(f-1) A third-party payor may request an itemized statement for billed charges of $10,000 or less.

(f-2) A third-party payor may request additional information, including medical records and operative reports, relating to a claim that has been submitted for payment to the third-party payor.

(f-3) The facility shall provide the itemized statement requested under Subsection (f-1) or the information requested under Subsection (f-2) as soon as practicable. The days between the date a third-party payor requests the itemized statement or additional information from the facility and the date the payor receives the itemized statement or information may not be counted in a payment period established by statute or under contract.

(f-4) The facility may provide the third-party payor with an electronic copy of an itemized statement under this section [not later than the 30th day after the date on which the payor requests the statement].

(f-5) If a third-party payor receives a claim for payment of part [but not all] of the billed charges [services], the third-party payor is entitled to [may request] an itemized statement of only the billed charges [services] for which payment is claimed or to which any deduction or copayment applies.

(f-6) A third-party payor that requests an itemized statement under Subsection (f-1) or additional information under Subsection (f-2) must have evidence sufficient to prove the date the payor made the request, which may include a certified mail receipt or an electronic date stamp. Unless rebutted by sufficient evidence provided by a facility, the date the payor receives the itemized statement or additional information, as shown in the payor's records, is presumed to be the date of receipt for purposes of Subsection (f-3).

SECTION 3. Section 324.103, Health and Safety Code, is amended to read as follows:

Sec. 324.103. [CONSUMER] WAIVER PROHIBITED. The provisions of this chapter may not be waived, voided, or nullified by a contract or an agreement between a facility and a consumer or third-party payor.

SECTION 4. Subchapter C, Chapter 324, Health and Safety Code, is amended by adding Sections 324.104, 324.105, 324.106, and 324.107 to read as follows:

Sec. 324.104. CLAIM FOR PAYMENT FROM PREFERRED PROVIDER. (a) A preferred provider that directly or through its agent or assignee asserts that a claim for payment of a medical or health care service or supply provided to a consumer, including a claim for payment of the amount due for a disallowed discount on the service or supply provided, has not been timely or accurately paid shall provide written notification of the nonpayment or inaccuracy to the third-party payor not later than the first anniversary of the earlier of the date the preferred provider received payment from the payor or the date that payment was due. A preferred provider or agent that fails to provide the notification before that date is barred from asserting the claim of nonpayment or inaccuracy. The notice required by this subsection does not affect a statute of limitations applicable to a claim.

(b) If a patient is admitted to a preferred provider for more than 30 days, the preferred provider on request of a third-party payor shall provide an interim statement of the facility's billed charges to the third-party payor not later than the 10th day after the date the third-party payor submits the request.

Sec. 324.105. OVERPAYMENT AND REIMBURSEMENT. (a) A third-party payor may recover an overpayment to a preferred provider if:

(1) not later than the 180th day after the date the provider receives the payment, the payor provides written notice of the overpayment to the provider that includes the basis and specific reasons for the request for recovery of funds; and

(2) the provider does not make arrangements for repayment of the requested funds on or before the 45th day after the date the provider receives the notice.

(b) A third-party payor that fails to provide notice of overpayment by the 180th day after the date the preferred provider receives a payment on a claim is barred from recovering an overpayment on that claim.

(c) If a preferred provider disagrees with a request for recovery of an overpayment, the third-party payor shall allow the provider an opportunity to appeal, and the payor may not attempt to recover the overpayment until all appeal rights are exhausted.

(d) A preferred provider that fails to make a reimbursement required by this section shall pay, in addition to the reimbursement, a late penalty in an amount equal to 10 percent of the amount of the required reimbursement.

Sec. 324.106. APPLICABILITY TO ENTITIES CONTRACTING WITH PREFERRED PROVIDER OR THIRD-PARTY PAYOR. This subchapter applies to a person with whom:

(1) a preferred provider contracts to submit or collect a claim for payment; or

(2) a third-party payor contracts to process or pay a claim for payment by a preferred provider.

Sec. 324.107. APPLICABILITY OF OTHER LAW. If a provision of this chapter and a provision of Chapter 1301, Insurance Code, apply to the same person, conduct, or circumstance, Chapter 1301, Insurance Code, controls.

SECTION 5. The changes in law made by this Act to Chapter 324, Health and Safety Code, apply only to services or supplies provided by a health care facility to a consumer on or after the effective date of this Act. Services or supplies provided before the effective date of this Act are governed by the law in effect immediately before the effective date of this Act, and that law is continued in effect for that purpose.

SECTION 6. This Act takes effect September 1, 2009.