BILL ANALYSIS

H.B. 1631

By: Thompson

Insurance

Committee Report (Unamended)

BACKGROUND AND PURPOSE

Interested parties contend that an insurer may not withhold the designation of preferred provider to a qualified podiatrist who joins the professional practice that has a contract with a managed care plan and who complies with the terms and conditions of eligibility to be a preferred provider. There is no provision for an expedited credentialing process for such a qualified podiatrist as there is for a physician who joins an established medical group that has a current contract in force with a managed care plan.

H.B. 1631 seeks to address this disparity by providing for an expedited credentialing process for a podiatrist who joins a professional practice that has a current contract in force with a managed care plan.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

ANALYSIS

H.B. 1631 amends the Insurance Code to require an applicant podiatrist who joins an established professional practice that has a current contract in force with a managed care plan, in order to qualify for expedited credentialing and payment during the credentialing process, to be licensed in Texas by, and in good standing with, the Texas State Board of Podiatric Medical Examiners; submit all documentation and other information required by the issuer of the managed care plan as necessary to enable the issuer to begin the credentialing process required by the issuer to include a podiatrist in the issuer's health benefit plan network; and agree to comply with the terms of the managed care plan's participating provider contract currently in force with the applicant podiatrist's established professional practice.

H.B. 1631 requires the issuer of a managed care plan, on submission by the applicant podiatrist of certain information required by the issuer and for payment purposes only, to treat the applicant podiatrist as if the podiatrist were a participating provider in the health benefit plan network when the applicant podiatrist provides services to the managed care plan's enrollees, including authorizing the applicant podiatrist to collect copayments from the enrollees, and making payments to the applicant podiatrist. The bill authorizes the managed care plan, pending the approval of a submitted application, to exclude the applicant podiatrist from the managed care plan's directory of participating podiatrists, the managed care plan's website listing of participating podiatrists, or any other listing of participating podiatrists.

H.B. 1631 authorizes the managed care plan issuer, if on completion of the credentialing process the issuer determines that the applicant podiatrist does not meet the issuer's credentialing requirements, to recover from the applicant podiatrist or the podiatrist's professional practice an amount equal to the difference between payments for in-network benefits and out-of-network benefits. The bill authorizes the applicant podiatrist or the podiatrist's professional practice to retain any copayments collected or in the process of being collected as of the date of the issuer's determination.

H.B. 1631 establishes that an enrollee in the managed care plan is not responsible and requires the enrollee to be held harmless for the difference between in-network copayments paid by the enrollee to a podiatrist who is determined to be ineligible for credentialing and the managed care plan's charges for out-of-network services. The bill prohibits the podiatrist and the podiatrist's professional practice from charging the enrollee for any portion of the podiatrist's fee that is not paid or reimbursed by the enrollee's managed care plan. The bill exempts a compliant managed care plan issuer from liability for damages arising out of or in connection with, directly or indirectly, the payment by the issuer of an applicant podiatrist as if the podiatrist were a participating provider in the health benefit plan network.

H.B. 1631 defines "applicant podiatrist," "enrollee," "health care provider," "managed care plan," "participating provider," and "professional practice."

EFFECTIVE DATE

September 1, 2011.