By: Taylor of Galveston H.B. No. 2605
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to certain workers' compensation benefits and to the
  continuation and functions of the division of workers' compensation
  of the Texas Department of Insurance; providing an administrative
  violation.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 31.004(b), Insurance Code, is amended to
  read as follows:
         (b)  Unless continued as provided by Chapter 325, Government
  Code, the duties of the division of workers' compensation of the
  Texas Department of Insurance under Title 5, Labor Code, expire
  September 1, 2017 [2011], or another date designated by the
  legislature.
         SECTION 2.  Sections 1305.355(e), (f), and (g), Insurance
  Code, are amended to read as follows:
         (e)  A party to a medical dispute that remains unresolved
  after a review under this section is entitled to a hearing and [may
  seek] judicial review of the decision in accordance with Section
  1305.356.  The division of workers' compensation and the department
  are not considered to be parties to the medical dispute.
         (f)  A determination of an independent review organization
  related to a request for preauthorization or concurrent review is
  binding during the pendency of a dispute [any appeal,] and the
  carrier and network shall comply with the determination.
         (g)  If a contested case hearing or judicial review is not
  sought under Section 1305.356 [this section], the carrier and
  network shall comply with the independent review organization's
  determination.
         SECTION 3.  Subchapter H, Chapter 1305, Insurance Code, is
  amended by adding Section 1305.356 to read as follows:
         Sec. 1305.356.  CONTESTED CASE HEARING ON AND JUDICIAL
  REVIEW OF INDEPENDENT REVIEW. (a) A party to a medical dispute
  that remains unresolved after a review under Section 1305.355 is
  entitled to a contested case hearing. A hearing under this
  subsection shall be conducted by the department's division of
  workers' compensation in the same manner as a hearing conducted
  under Section 413.0311, Labor Code.
         (b)  At a contested case hearing held under Subsection (a),
  the hearing officer conducting the hearing shall consider
  evidence-based treatment guidelines adopted by the network under
  Section 1305.304.
         (c)  A party that has exhausted all administrative remedies
  under Subsection (a) and is aggrieved by a final decision of the
  department's division of workers' compensation may seek judicial
  review of the decision.
         (d)  Except as otherwise provided by this subsection,
  judicial review under Subsection (c) shall be conducted in the
  manner provided by Section 413.031(k-1), Labor Code. For judicial
  review of an independent review organization decision to which an
  injured employee is a party:
               (1)  venue shall be as provided by Section 410.252,
  Labor Code; and
               (2)  service and notice shall be as provided by Section
  410.253, Labor Code.
         SECTION 4.  Section 2051.151(e), Insurance Code, is amended
  to read as follows:
         (e)  An insurance company that fails to comply with this
  section commits an [a Class D] administrative violation under
  Subtitle A, Title 5, Labor Code.
         SECTION 5.  Section 2053.206(a), Insurance Code, is amended
  to read as follows:
         (a)  A person commits an [a Class A] administrative violation
  under Subtitle A, Title 5, Labor Code, if the person engages in
  conduct that violates this subchapter.
         SECTION 6.  Section 402.023, Labor Code, is amended by
  adding Subsection (c-1) to read as follows:
         (c-1)  The division shall adopt a policy outlining the
  division's complaint process from receipt of the initial complaint
  to the complaint's disposition.
         SECTION 7.  Subchapter B, Chapter 402, Labor Code, is
  amended by adding Section 402.0231 to read as follows:
         Sec. 402.0231.  DOCUMENTATION AND ANALYSIS OF COMPLAINTS.
  (a)  The division shall develop procedures to formally document and
  analyze complaints received by the division.
         (b)  The division shall compile detailed statistics on all
  complaints received and analyze complaint information trends,
  including:
               (1)  the number of complaints;
               (2)  the source of each complaint;
               (3)  the types of complaints;
               (4)  the length of time from the receipt of the
  complaint to its disposition; and
               (5)  the disposition of complaints.
         (c)  The division shall further analyze the information
  compiled under Subsection (b) by field office and by program.
         (d)  The division shall report the information compiled and
  analyzed under Subsections (b) and (c) to the commissioner at
  regular intervals.
         SECTION 8.  Section 402.073, Labor Code, is amended to read
  as follows:
         Sec. 402.073.  COOPERATION WITH STATE OFFICE OF
  ADMINISTRATIVE HEARINGS. (a) The commissioner and the chief
  administrative law judge of the State Office of Administrative
  Hearings [by rule] shall adopt a memorandum of understanding
  governing administrative procedure law hearings under this
  subtitle conducted by the State Office of Administrative Hearings
  in the manner provided for a contested case hearing under Chapter
  2001, Government Code. The memorandum of understanding must
  address the payment of costs by parties to a medical fee dispute
  under Section 413.0312.
         (b)  In a case in which a hearing is conducted by the State
  Office of Administrative Hearings under Section 413.031 or [,]
  413.055, [or 415.034,] the administrative law judge who conducts
  the hearing for the State Office of Administrative Hearings shall
  enter the final decision in the case after completion of the
  hearing.
         (c)  In a case in which a hearing is conducted in conjunction
  with Section 402.072, 407.046, [or] 408.023, or 415.034, and in
  other cases under this subtitle that are not subject to Subsection
  (b), the administrative law judge who conducts the hearing for the
  State Office of Administrative Hearings shall propose a decision to
  the commissioner for final consideration and decision by the
  commissioner.
         (d)  The notice of the commissioner's order must include a
  statement of the right of the person to judicial review of the
  order.
         (e)  In issuing an order under this section, the commissioner
  shall comply with the requirements applicable to a state agency
  under Section 2001.058, Government Code.
         SECTION 9.  Section 403.001(a), Labor Code, is amended to
  read as follows:
         (a)  Except as provided by Sections 403.006, [and] 403.007,
  and 403.008, or as otherwise provided by law, money collected under
  this subtitle, including [administrative penalties and] advance
  deposits for purchase of services, shall be deposited in the
  general revenue fund of the state treasury to the credit of the
  Texas Department of Insurance operating account.
         SECTION 10.  Chapter 403, Labor Code, is amended by adding
  Section 403.008 to read as follows:
         Sec. 403.008.  DEPOSIT OF ADMINISTRATIVE PENALTIES.
  Administrative penalties collected under this subtitle shall be
  deposited in the general revenue fund.
         SECTION 11.  Section 408.0041, Labor Code, is amended by
  amending Subsection (b) and adding Subsection (b-1) to read as
  follows:
         (b)  Except as provided by Section 408.1225(f), a [A] medical
  examination requested under Subsection (a) shall be performed by
  the next available doctor on the division's list of certified 
  designated doctors whose credentials are appropriate for the area
  of the body affected by the injury [issue in question] and the
  injured employee's diagnosis [medical condition] as determined by
  commissioner rule.  [A designated doctor, other than a
  chiropractor, is subject to Section 408.0043. A designated doctor
  who is a chiropractor is subject to Section 408.0045.] The division
  shall assign a designated doctor not later than the 10th day after
  the date on which the request under Subsection (a) is approved, and
  the examination must be conducted not later than the 21st day after
  the date on which the commissioner issues the order under
  Subsection (a).  An examination under this section may not be
  conducted more frequently than every 60 days, unless good cause for
  more frequent examinations exists, as defined by commissioner
  rules.
         (b-1)  A designated doctor, other than a chiropractor, is
  subject to Section 408.0043. A designated doctor who is a
  chiropractor is subject to Section 408.0045. To the extent of a
  conflict between this section and Section 408.0043 or 408.0045,
  this section controls.
         SECTION 12.  Section 408.023(r), Labor Code, is amended to
  read as follows:
         (r)  Notwithstanding the waiver or expiration of Subsections
  (a)-(g) and (i), there may be no direct or indirect provision of
  health care under this subtitle and rules adopted under this
  subtitle, and no direct or indirect receipt of remuneration under
  this subtitle and rules adopted under this subtitle by a doctor who:
               (1)  before September 1, 2007:
                     (A)  was removed or deleted from the list of
  approved doctors either by action of the Texas Workers'
  Compensation Commission or the division or by agreement with the
  doctor;
                     (B)  was not admitted to the list of approved
  doctors either by action of the Texas Workers' Compensation
  Commission or the division or by agreement with the doctor;
                     (C)  was suspended from the list of approved
  doctors either by action of the Texas Workers' Compensation
  Commission or the division or by agreement with the doctor; or
                     (D)  had the doctor's license to practice
  suspended by the appropriate licensing agency, including a
  suspension that was stayed, deferred, or probated, or voluntarily
  relinquished the license to practice; and
               (2)  was not reinstated or restored by the Texas
  Workers' Compensation Commission or the division:
                     (A)  to the list of approved doctors; or
                     (B)  to the workers' compensation system [before
  September 1, 2007].
         SECTION 13.  Section 408.1225, Labor Code, is amended by
  amending Subsections (a), (b), and (e) and adding Subsections
  (a-1), (a-2), (a-3), (a-4), (a-5), and (f) to read as follows:
         (a)  To be eligible to serve as a designated doctor, a doctor
  must maintain an active certification by the division [meet
  specific qualifications, including training in the determination
  of impairment ratings and demonstrated expertise in performing
  examinations and making evaluations as described by Section
  408.0041.   The commissioner shall develop qualification standards
  and administrative policies to implement this subsection and may
  adopt rules as necessary].
         (a-1)  The commissioner by rule shall develop a process for
  the certification of a designated doctor.
         (a-2)  The rules adopted by the commissioner under
  Subsection (a-1) must:
               (1)  require the division to evaluate the qualification
  of designated doctors for certification using eligibility
  requirements, including:
                     (A)  educational experience;
                     (B)  previous training; and
                     (C)  demonstrated ability to perform the specific
  designated doctor duties described by Section 408.0041; and
               (2)  require standard training and testing to be
  completed in accordance with policies and guidelines developed by
  the division.
         (a-3)  The division shall develop guidelines for
  certification training programs for certification of a designated
  doctor under Subsection (a-1) to ensure a designated doctor's
  competency and continued competency in providing assessments,
  including:
               (1)  a standard curriculum;
               (2)  standard course materials; and
               (3)  testing criteria.
         (a-4)  The division shall develop and implement a procedure
  to periodically review and update the guidelines developed under
  Subsection (a-3).
         (a-5)  The division may authorize an independent training
  and testing provider to conduct the certification program for the
  division under the guidelines developed under Subsection (a-3).  
  The division shall solicit proposals or applications from
  independent training and testing providers and shall make public on
  its website a complete list of providers that are authorized to
  conduct the certification training program developed under
  Subsection (a-3).
         (b)  The commissioner shall ensure the quality of designated
  doctor decisions and reviews through active monitoring of the
  decisions and reviews, and may take action as necessary to:
               (1)  restrict the participation of a designated doctor;
  [or]
               (2)  deny renewal of [remove] a [doctor from inclusion
  on the department's list of] designated doctor's certification; or
               (3)  revoke a designated doctor's certification under
  Section 413.044 [doctors].
         (e)  A designated doctor, other than a chiropractor, is
  subject to Section 408.0043.  A designated doctor who is a
  chiropractor is subject to Section 408.0045. To the extent of a
  conflict between this section and Section 408.0043 or 408.0045,
  this section controls.
         (f)  A designated doctor shall continue providing services
  related to a case assigned to the designated doctor, including
  performing subsequent examinations or acting as a resource for
  division disputes, unless the division authorizes the designated
  doctor to discontinue providing services. The commissioner by rule
  shall prescribe the circumstances under which a designated doctor
  is permitted to discontinue providing services, including:
               (1)  the doctor decides to stop practicing in the
  workers' compensation system; or
               (2)  the doctor relocates the doctor's residence or
  practice.
         SECTION 14.  Section 409.021(e), Labor Code, is amended to
  read as follows:
         (e)  An insurance carrier commits an administrative [a]
  violation if the insurance carrier does not initiate payments or
  file a notice of refusal as required by this section. [A violation
  under this subsection shall be assessed at $500 if the carrier
  initiates compensation or files a notice of refusal within five
  working days of the date required by Subsection (a), $1,500 if the
  carrier initiates compensation or files a notice of refusal more
  than five and less than 16 working days of the date required by
  Subsection (a), $2,500 if the carrier initiates compensation or
  files a notice of refusal more than 15 and less than 31 working days
  of the date required by Subsection (a), or $5,000 if the carrier
  initiates compensation or files a notice of refusal more than 30
  days after the date required by Subsection (a). The administrative
  penalties are not cumulative.]
         SECTION 15.  Section 410.023, Labor Code, is amended by
  amending Subsection (b) and adding Subsections (c) and (d) to read
  as follows:
         (b)  The division shall require the party requesting the
  benefit review conference to provide documentation of efforts made
  to resolve the disputed issues before the request was submitted.
         (c)  The commissioner by rule shall:
               (1)  adopt guidelines regarding the type of information
  necessary to satisfy the requirements of Subsection (b); and
               (2)  establish a process through which the division
  evaluates the sufficiency of the documentation provided under
  Subsection (b) [this requirement].
         (d)  The division may deny a request for a benefit review
  conference if the party requesting the benefit review conference
  does not provide the documentation required under Subsection (b).
         SECTION 16.  Section 410.028, Labor Code, is amended to read
  as follows:
         Sec. 410.028.  FAILURE TO ATTEND; ADMINISTRATIVE VIOLATION.
  (a) A scheduled benefit review conference shall be conducted even
  though a party fails to attend unless the benefit review officer
  determines that good cause, as defined by commissioner rule, exists
  to reschedule the conference.
         (b)  If a party to a benefit review conference under Section
  410.023 requests that the benefit review conference be rescheduled
  under this section, the party must submit a request in the same
  manner as an initial request under Section 410.023. The division
  shall evaluate a request for a rescheduled benefit review
  conference received under this section in the same manner as an
  initial request received under Section 410.023.
         (c)  If a [A party commits an administrative violation if
  the] party fails to request that a benefit review conference be
  rescheduled in the time required by commissioner rule or fails to
  attend a benefit review conference without good cause as defined
  [determined] by commissioner rule, the party forfeits the party's
  entitlement to attend a benefit review conference on the issue in
  dispute, unless a [the] benefit review officer is authorized to
  schedule an additional benefit review conference under Section
  410.026(b).
         (d)  The commissioner shall adopt rules necessary to
  implement and enforce this section, including rules that:
               (1)  define good cause; and
               (2)  establish deadlines for requesting that a benefit
  review conference be rescheduled under Subsection (b).
         SECTION 17.  Section 410.203(b), Labor Code, is amended to
  read as follows:
         (b)  The appeals panel may:
               (1)  reverse the decision of the hearings officer and
  render a new decision; [or]
               (2)  reverse the decision of the hearings officer and
  remand the case to the hearing officer for further consideration
  and development of evidence; or
               (3)  affirm the decision of the hearings officer in a
  case described by Section 410.204(a-1).
         SECTION 18.  Section 410.204, Labor Code, is amended by
  amending Subsection (a) and adding Subsection (a-1) to read as
  follows:
         (a)  The appeals panel shall review each request and issue a
  written decision on each reversed or remanded case.  The appeals
  panel may issue a written decision on an affirmed case as described
  by Subsection (a-1).  The decision must be in writing and shall be
  issued not later than the 45th day after the date on which the
  written response to the request for appeal is filed.  The appeals
  panel shall file a copy of the decision with the commissioner.
         (a-1)  An appeals panel may only issue a written decision in
  a case in which the panel affirms the decision of a hearings officer
  if the case:
               (1)  is a case of first impression;
               (2)  involves a recent change in law; or
               (3)  involves errors at the contested case hearing that
  require correction but do not affect the outcome of the hearing,
  including:
                     (A)  findings of fact for which insufficient
  evidence exists;
                     (B)  incorrect conclusions of law;
                     (C)  findings of fact or conclusions of law
  regarding matters that were not properly before the hearings
  officer; and
                     (D)  legal errors not otherwise described by this
  subdivision.
         SECTION 19.  Sections 413.031(k) and (k-1), Labor Code, are
  amended to read as follows:
         (k)  A party to a medical dispute [, other than a medical
  dispute regarding spinal surgery subject to Subsection (l) and a
  dispute subject to Section 413.0311,] that remains unresolved after
  a review of the medical service under this section is entitled to a
  hearing under Section 413.0311 or 413.0312, as applicable.  [A
  hearing under this subsection shall be conducted by the State
  Office of Administrative Hearings not later than the 60th day after
  the date on which the party notifies the division of the request for
  a hearing.   The hearing shall be conducted in the manner provided
  for a contested case under Chapter 2001, Government Code.]
         (k-1)  A party who has exhausted all administrative remedies
  described by [under] Subsection (k) and who is aggrieved by a final
  decision of the division or the State Office of Administrative
  Hearings may seek judicial review of the decision.  Except as
  otherwise provided by this subsection, Section 413.0311(d) of this
  code, or Section 1305.356(d), Insurance Code, judicial [Judicial]
  review under this subsection shall be conducted in the manner
  provided for judicial review of a contested case under Subchapter
  G, Chapter 2001, Government Code.  The standard of review shall be
  as provided by Section 2001.174, Government Code.  The court shall
  conduct the review without a jury as provided by Section
  2001.175(e), Government Code. The time to file a petition shall be
  as provided by Section 410.252.
         SECTION 20.  The heading to Section 413.0311, Labor Code, is
  amended to read as follows:
         Sec. 413.0311.  REVIEW OF [CERTAIN] MEDICAL NECESSITY
  DISPUTES; CONTESTED CASE HEARING.
         SECTION 21.  Sections 413.0311(a) and (d), Labor Code, are
  amended to read as follows:
         (a)  This section applies only to [the following medical
  disputes that remain unresolved after any applicable review under
  Sections 413.031(b) through (i):
               [(1)     a medical fee dispute in which the amount of
  reimbursement sought by the requestor in its request for medical
  dispute resolution does not exceed $2,000;
               [(2)]  an appeal of an independent review organization
  decision regarding determination of the [retrospective] medical
  necessity for a health care service [for which the amount billed
  does not exceed $3,000; and
               [(3)     an appeal of an independent review organization
  decision regarding determination of the concurrent or prospective
  medical necessity for a health care service].
         (d)  A party who has exhausted all administrative remedies
  under Section 413.031 and this section and who is aggrieved by a
  final decision of the hearings officer under Subsection (c) may
  seek judicial review of the decision. Except as otherwise provided
  by this subsection, judicial  [Judicial] review under this
  subsection shall be conducted in the manner provided by Section
  413.031(k-1). For [for] judicial review of an independent review
  organization decision to which an injured employee is a party:
               (1)  venue shall be as provided by Section 410.252; and
               (2)  service and notice shall be as provided by Section
  410.253 [a contested case under Subchapter G, Chapter 2001,
  Government Code].
         SECTION 22.  Subchapter C, Chapter 413, Labor Code, is
  amended by adding Section 413.0312 to read as follows:
         Sec. 413.0312.  REVIEW OF MEDICAL FEE DISPUTES; BENEFIT
  REVIEW CONFERENCE. (a) This section applies only to a medical fee
  dispute that remains unresolved after any applicable review under
  Sections 413.031(b) through (i).
         (b)  Subject to Subsection (e), a party to a medical fee
  dispute described by Subsection (a) must adjudicate the dispute in
  the manner required by Subchapter B, Chapter 410.
         (c)  At a benefit review conference conducted under this
  section, the parties to the dispute may not resolve the dispute by
  negotiating fees that are inconsistent with any applicable fee
  guidelines adopted by the commissioner.
         (d)  If issues remain unresolved after a benefit review
  conference, the parties may elect to engage in arbitration as
  provided by Section 410.104.
         (e)  If arbitration is not elected as described by Subsection
  (d), a party to a medical fee dispute described by Subsection (a) is
  entitled to a contested case hearing. A hearing under this
  subsection shall be conducted by the State Office of Administrative
  Hearings in the manner provided for a contested case under Chapter
  2001, Government Code.
         (f)  The commissioner or the division may participate in a
  contested case hearing conducted under Subsection (e) if the
  hearing involves the interpretation of fee guidelines adopted by
  the commissioner. The division and the department are not
  considered to be parties to the medical fee dispute for purposes of
  this section.
         (g)  Except as otherwise provided by this subsection, the
  nonprevailing party shall reimburse the division for the costs for
  services provided by the State Office of Administrative Hearings
  under this section. If the injured employee is the nonprevailing
  party, the insurance carrier shall reimburse the division for the
  costs for services provided by the State Office of Administrative
  Hearings under this section. The party required to reimburse the
  division under this subsection shall remit payment to the division
  not later than the 30th day after the date of receiving a bill or
  statement from the division.
         (h)  The State Office of Administrative Hearings shall
  timely notify the division if a dispute is dismissed before
  issuance of a decision under this section. In the event of a
  dismissal, the party requesting the hearing, other than the injured
  employee, shall reimburse the division for the costs for services
  provided by the State Office of Administrative Hearings unless
  otherwise agreed by the parties. If the injured employee requested
  the hearing, the insurance carrier shall reimburse the division for
  the costs for services provided by the State Office of
  Administrative Hearings unless otherwise agreed by the parties.  
  The responsible party shall remit payment to the division not later
  than the 30th day after the date of receiving a bill or statement
  from the division.
         (i)  The State Office of Administrative Hearings shall
  identify the nonprevailing party and any costs for services
  provided by the office under this section in its final decision.
  Money collected by the division under this section shall be
  deposited in the general revenue fund to the credit of the Texas
  Department of Insurance operating account.
         (j)  Interest on the amount of reimbursement required by this
  section that remains unpaid accrues at a rate provided by Section
  401.023 beginning on the 45th day after the date the division
  submits the bill or statement to a party until the date the
  reimbursement is paid. Failure to pay the division as required by
  this section is an administrative violation under this subtitle.
         (k)  The commissioner by rule shall establish procedures to
  enable the division to charge a party to a medical fee dispute,
  other than an injured employee, for the costs of services provided
  by the State Office of Administrative Hearings.
         SECTION 23.  Section 413.044(b), Labor Code, is amended to
  read as follows:
         (b)  Sanctions imposed under Subsection (a) may include:
               (1)  revocation of certification for a designated
  doctor on [removal or suspension from] the division list of
  designated doctors; or
               (2)  restrictions on the reviews made by the person as a
  designated doctor.
         SECTION 24.  Section 413.0512, Labor Code, is amended by
  amending Subsections (b), (c), (d), (e), and (f) and adding
  Subsections (g) and (h) to read as follows:
         (b)  The agencies that regulate health professionals who are
  licensed or otherwise authorized to practice a health profession
  under Title 3, Occupations Code, and who are involved in the
  provision of health care as part of the workers' compensation
  system in this state [Texas State Board of Medical Examiners and the
  Texas Board of Chiropractic Examiners, with input from their
  respective professional associations,] shall develop lists of
  health care providers [physicians and chiropractors] licensed or
  otherwise regulated by those agencies who have demonstrated
  experience in workers' compensation or utilization review. The
  medical advisor shall consider appointing some of the members of
  the medical quality review panel from the names on those lists and,
  when appointing members of the medical quality review panel, shall
  select specialists from various health care specialty fields to
  serve on the panel to ensure that the membership of the panel has
  expertise in a wide variety of health care specialty fields. The
  medical advisor shall also consider nominations for the panel made
  by labor, business, and insurance organizations.
         (c)  The medical quality review panel shall recommend to the
  medical advisor:
               (1)  appropriate action regarding doctors, other
  health care providers, insurance carriers, utilization review
  agents, and independent review organizations; [and]
               (2)  the addition or deletion of doctors from the list
  of approved doctors under Section 408.023; and
               (3)  the certification, revocation of certification,
  or denial of renewal of certification [or the list] of a designated
  doctor [doctors established] under Section 408.1225.
         (d)  A person who serves on the medical quality review panel
  is immune from suit and from civil liability for an act performed,
  or a recommendation made, within the scope of the person's
  functions as a member of the panel if the person acts without malice
  and in the reasonable belief that the action or recommendation is
  warranted by the facts known to that person. In the event of a civil
  action brought against a member of the panel that arises from the
  person's participation on the panel, the person is entitled to the
  same protections afforded the commissioner [a commission member]
  under Section 402.00123 [402.010].
         (e)  The actions of a person serving on the medical quality
  review panel do not constitute utilization review and are not
  subject to Chapter 4201 [Article 21.58A], Insurance Code.
         (f)  A member of the medical quality review panel[, other
  than a chiropractor,] who reviews a specific workers' compensation
  case is subject to Section 408.0043, 408.0044, or [.   A chiropractor
  who reviews a specific workers' compensation case is subject to
  Section] 408.0045, as applicable.
         (g)  The medical advisor shall notify the division if the
  medical advisor determines that:
               (1)  it is no longer necessary for the medical quality
  review panel to include a member that practices in a particular
  health care specialty field; or
               (2)  there is a need for the panel to include a member
  that practices in a particular health care specialty field not
  represented on the panel.
         (h)  If the division receives notice from the medical advisor
  under Subsection (g)(2), the division may enter into agreements
  with other state agencies to access, as necessary, expertise in
  that health care specialty field.
         SECTION 25.  Subchapter E, Chapter 413, Labor Code, is
  amended by adding Sections 413.05115, 413.05121, and 413.05122 to
  read as follows:
         Sec. 413.05115.  MEDICAL QUALITY REVIEW PROCESS. (a)  The
  division shall develop, and the commissioner shall adopt, criteria
  concerning the medical case review process under this subchapter.
  In developing the criteria, and before adopting the criteria, the
  division and the commissioner, as applicable, must consult with the
  medical advisor and seek input from potentially affected parties,
  including health care providers and insurance carriers.
         (b)  The criteria developed and adopted under this section
  must establish a clear process or processes:
               (1)  for handling complaint-based medical case
  reviews; and
               (2)  through which the division selects health care
  providers or other entities for a compliance audit or review.
         (c)  The division shall make the criteria developed and
  adopted under this section available on the Internet website
  maintained by the division.
         Sec. 413.05121.  QUALITY ASSURANCE PANEL. (a) The medical
  advisor shall establish the quality assurance panel within the
  medical quality review panel to:
               (1)  provide an additional level of evaluation in
  medical case reviews; and
               (2)  assist the medical advisor in performing the
  advisor's duties under Section 413.0511(b)(6) and the medical
  quality review panel in performing that panel's duties under
  Section 413.0512.
         (b)  Members of the quality assurance panel shall evaluate
  medical care and recommend enforcement actions to the medical
  advisor.
         (c)  The quality assurance panel shall meet periodically to
  discuss issues and otherwise offer assistance to the medical
  advisor and the medical quality review panel under Subsection
  (a)(2).
         Sec. 413.05122.  MEDICAL QUALITY REVIEW PANEL: RULES;
  TRAINING. (a)  The commissioner, after consultation with the
  medical advisor, shall adopt rules concerning the operation of the
  medical quality review panel, including rules that establish:
               (1)  the qualifications necessary for a health care
  provider to serve on the medical quality review panel;
               (2)  the composition of the medical quality review
  panel, including the number of members to be included on the panel
  and the health care specialty fields required to be represented by
  the members of the panel;
               (3)  the maximum length of time a health care provider
  may serve on the medical quality review panel;
               (4)  a policy defining situations that constitute a
  conflict of interest for a member of the medical quality review
  panel;
               (5)  procedures and grounds for removing a member of
  the medical quality review panel from the panel, including as a
  ground for removal that a member is repeatedly delinquent in
  conducting case reviews; and
               (6)  a procedure through which members of the medical
  quality review panel are notified concerning the status and
  enforcement outcomes of cases resulting from the medical quality
  review process.
         (b)  In addition to the rules required under Subsection (a),
  the commissioner shall adopt rules concerning the training
  requirements for members of the medical quality review panel. The
  rules adopted under this subsection must ensure that panel members
  are fully aware of any requirements imposed by this subtitle
  concerning the medical quality review process and the division's
  goals concerning the process. The rules adopted under this
  subsection may require members to receive training on any topic
  determined by the division or the commissioner to be relevant to the
  operations of the panel and must require members of the panel to
  receive training concerning:
               (1)  administrative violations that affect the
  delivery of appropriate medical care;
               (2)  the confidentiality requirements described by
  Section 413.0513 and the immunity from liability provided to
  members of the panel under Section 413.054; and
               (3)  the medical quality review criteria adopted under
  Section 413.05115.
         SECTION 26.  Section 413.054(a), Labor Code, is amended to
  read as follows:
         (a)  A person who performs services for the division as a
  designated doctor, an independent medical examiner, a doctor
  performing a medical case review, or a member of a peer review panel
  has the same immunity from liability as the commissioner under
  Section 402.00123 [402.0024].
         SECTION 27.  Section 414.005, Labor Code, is amended to read
  as follows:
         Sec. 414.005.  INVESTIGATION UNIT.  (a)  The division shall
  maintain an investigation unit to conduct investigations relating
  to alleged violations of this subtitle, commissioner rules, or a
  commissioner order or decision, with particular emphasis on
  violations of Chapters 415 and 416.
         (b)  As often as the commissioner considers necessary, the
  commissioner or the investigation unit may review the operations of
  a person regulated by the division, including an agent of the person
  performing functions regulated by the division, to determine
  compliance with this subtitle.
         (c)  The review described by Subsection (b) may include
  on-site visits to the person's premises. The commissioner is not
  required to announce an on-site visit in advance.
         (d)  During an on-site visit, a person regulated by the
  division shall make available to the division all records relating
  to the person's participation in the workers' compensation system.
         (e)  The commissioner by rule shall prescribe the procedures
  to be used for both announced and unannounced on-site visits
  authorized under this section, including specifying the types of
  records subject to inspection.
         SECTION 28.  Section 415.0035(e), Labor Code, is amended to
  read as follows:
         (e)  A person regulated by the division under this title [An
  insurance carrier or health care provider] commits an
  administrative violation if the [that] person violates this
  subtitle or a rule, order, or decision of the commissioner.
         SECTION 29.  Section 415.008(a), Labor Code, is amended to
  read as follows:
         (a)  A person commits an administrative [a] violation if the
  person, to obtain or deny a payment of a workers' compensation
  benefit or the provision of a benefit for the person or another,
  knowingly or intentionally:
               (1)  makes a false or misleading statement;
               (2)  misrepresents or conceals a material fact;
               (3)  fabricates, alters, conceals, or destroys a
  document; or
               (4)  conspires to commit an act described by
  Subdivision (1), (2), or (3).
         SECTION 30.  Sections 415.009 and 415.010, Labor Code, are
  amended to read as follows:
         Sec. 415.009.  FRIVOLOUS ACTIONS; ADMINISTRATIVE VIOLATION.
  [(a)] A person commits an administrative [a] violation if the
  person brings, prosecutes, or defends an action for benefits under
  this subtitle or requests initiation of an administrative violation
  proceeding that does not have a basis in fact or is not warranted by
  existing law or a good faith argument for the extension,
  modification, or reversal of existing law.
         [(b)     A violation under Subsection (a) is a Class B
  administrative violation.]
         Sec. 415.010.  BREACH OF AGREEMENT; ADMINISTRATIVE
  VIOLATION. [(a)] A party to an agreement approved by the division
  commits an administrative [a] violation if the person breaches a
  provision of the agreement.
         [(b)     A violation under Subsection (a) is a Class C
  administrative violation.]
         SECTION 31.  The heading to Subchapter B, Chapter 415, Labor
  Code, is amended to read as follows:
  SUBCHAPTER B. SANCTIONS [PENALTIES]
         SECTION 32.  Section 415.021(a), Labor Code, is amended to
  read as follows:
         (a)  In addition to any other provisions in this subtitle
  relating to violations, a person commits an administrative
  violation if the person violates, fails to comply with, or refuses
  to comply with this subtitle or a rule, order, or decision of the
  commissioner, including an emergency cease and desist order issued
  under Section 415.0211.  In addition to any sanctions,
  administrative penalty, or other remedy authorized by this
  subtitle, the commissioner may assess an administrative penalty
  against a person who commits an administrative violation.  The
  administrative penalty shall not exceed $25,000 per day per
  occurrence.  Each day of noncompliance constitutes a separate
  violation.  The commissioner's authority under this chapter is in
  addition to any other authority to enforce a sanction, penalty,
  fine, forfeiture, denial, suspension, or revocation otherwise
  authorized by law.
         SECTION 33.  Subchapter B, Chapter 415, Labor Code, is
  amended by adding Section 415.0211 to read as follows:
         Sec. 415.0211.  EMERGENCY CEASE AND DESIST ORDER. (a) The
  commissioner ex parte may issue an emergency cease and desist order
  if:
               (1)  the commissioner believes a person regulated by
  the division under this title is engaging in conduct violating a
  law, rule, or order; and
               (2)  the commissioner believes that the alleged conduct
  under Subdivision (1) will result in harm to the health, safety, or
  welfare of another person.
         (b)  On issuance of an order under Subsection (a), the
  commissioner shall serve on the affected person an order that
  contains a statement of the charges and requires the person
  immediately to cease and desist from the acts, methods, or
  practices stated in the order. The commissioner shall serve the
  order by registered or certified mail, return receipt requested, to
  the affected person's last known address.  The order is final on the
  31st day after the date the affected person receives the order,
  unless the affected person requests a hearing under Subsection (c).
         (c)  A person affected by an order is entitled to request a
  hearing to contest the order. The affected person must request the
  hearing not later than the 30th day after the date the person
  receives the order required by Subsection (b). A request to contest
  an order must:
               (1)  be in writing;
               (2)  be directed to the commissioner; and
               (3)  state the grounds for the request to set aside or
  modify the order.
         (d)  On receiving a request for a hearing, the commissioner
  shall serve notice of the time and place of the hearing. The
  hearing is subject to the procedures for a contested case under
  Chapter 2001, Government Code. The hearing shall be held not later
  than the 10th day after the date the commissioner receives the
  request for a hearing unless the parties mutually agree to a later
  hearing date. At the hearing, the person requesting the hearing is
  entitled to show cause why the order should not be affirmed.
  Following receipt of the proposal for decision from the State
  Office of Administrative Hearings regarding the hearing, the
  commissioner shall wholly or partly affirm, modify, or set aside
  the order.
         (e)  Pending a hearing under this section, an order continues
  in effect unless the order is stayed by the commissioner.
         SECTION 34.  Section 402.072, Labor Code, is transferred to
  Subchapter B, Chapter 415, Labor Code, and redesignated as Section
  415.0215, Labor Code, to read as follows:
         Sec. 415.0215 [402.072].  SANCTIONS. (a) The division may
  impose sanctions against any person regulated by the division under
  this subtitle.
         (b)  Only the commissioner may impose:
               (1)  a sanction that deprives a person of the right to
  practice before the division or of the right to receive
  remuneration under this subtitle for a period exceeding 30 days; or
               (2)  another sanction suspending for more than 30 days
  or revoking a license, certification, or permit required for
  practice in the field of workers' compensation.
         (c)  A sanction imposed by the division is binding pending
  appeal.
         SECTION 35.  Sections 415.025, 415.032, 415.033, and
  415.034, Labor Code, are amended to read as follows:
         Sec. 415.025.  REFERENCES TO A CLASS OF VIOLATION OR
  PENALTY. A reference in this code or other law, or in rules of the
  former Texas Workers' Compensation Commission or the commissioner,
  to a particular class of violation, administrative violation, or
  penalty shall be construed as a reference to an administrative
  penalty. An [Except as otherwise provided by this subtitle, an]
  administrative penalty may not exceed $25,000 per day per
  occurrence.  Each day of noncompliance constitutes a separate
  violation.
         Sec. 415.032.  NOTICE OF POSSIBLE ADMINISTRATIVE VIOLATION;
  RESPONSE. (a) If investigation by the division indicates that an
  administrative violation has occurred, the division shall notify
  the person alleged to have committed the violation in writing of:
               (1)  the charge;
               (2)  the proposed sanction [penalty];
               (3)  the right to consent to the charge and the sanction 
  [penalty]; and
               (4)  the right to request a hearing.
         (b)  Not later than the 20th day after the date on which
  notice is received, the charged party shall:
               (1)  remit the amount of the sanction [penalty] to the
  division or otherwise consent to the imposed sanction; or
               (2)  submit to the division a written request for a
  hearing.
         Sec. 415.033.  FAILURE TO RESPOND. If, without good cause, a
  charged party fails to respond as required under Section 415.032,
  [the penalty is due and] the division shall initiate enforcement
  proceedings.
         Sec. 415.034.  HEARING PROCEDURES. [(a)] On the request of
  the charged party or the commissioner, the State Office of
  Administrative Hearings shall set a hearing.  The hearing shall be
  conducted in the manner provided for a contested case under Chapter
  2001, Government Code (the administrative procedure law).
         [(b)     At the close of the hearing, the hearing officer
  conducting the hearing shall make findings of fact and conclusions
  of law and shall issue a written decision. If the hearing officer
  determines that an administrative violation has occurred, the
  hearing officer shall include in the decision the amount of the
  administrative penalty assessed and shall order payment of the
  penalty.
         [(c)     The findings of fact, the decision, and the order shall
  be sent immediately to the charged party.]
         SECTION 36.  Subchapter C, Chapter 415, Labor Code, is
  amended by adding Section 415.036 to read as follows:
         Sec. 415.036.  STANDARD OF JUDICIAL REVIEW OF COMMISSIONER'S
  ORDER. An order of the commissioner is subject to judicial review
  under the substantial evidence rule.
         SECTION 37.  Section 419.001, Labor Code, is amended by
  adding Subsection (c) to read as follows:
         (c)  For purposes of this chapter, a person acts in a
  "deceptive manner" if the person knows or should know that the
  person's actions would convey, or could reasonably be interpreted
  or construed as conveying, the false impression that:
               (1)  an item is approved, endorsed, sponsored,
  authorized by, the same as, or associated with the division, the
  department, this state, or an agency of this state; or
               (2)  the person has a connection with or authorization
  from the division, the department, this state, or an agency of this
  state.
         SECTION 38.  Section 419.002, Labor Code, is amended to read
  as follows:
         Sec. 419.002.  MISUSE OF DIVISION'S NAME OR SYMBOLS
  PROHIBITED. (a) Except as authorized by law, a person, in
  connection with any impersonation, advertisement, solicitation,
  business name, business activity, document, product, or service
  made or offered by the person regarding workers' compensation
  coverage or benefits, may not knowingly use or cause to be used in a
  deceptive manner:
               (1)  the words "Texas Department of Insurance,"
  "Department of Insurance," "Texas Workers' Compensation," or
  "division of workers' compensation";
               (2)  any term using both "Texas" and "Workers'
  Compensation" or any term using both "Texas" and "Workers' Comp";
               (3)  the initials "T.D.I."; or
               (4)  any combination or variation of the words or
  initials, or any term deceptively similar to the words or initials,
  described by Subdivisions (1)-(3).
         (b)  A person subject to Subsection (a) may not knowingly use
  or cause to be used in a deceptive manner a word, term, or initials
  described by Subsection (a) alone or in conjunction with:
               (1)  the state seal or a representation of the state
  seal;
               (2)  a picture or map of this state; or
               (3)  the official logo of the department or the
  division or a representation of the department's or division's
  logo.
         SECTION 39.  Subchapter C, Chapter 504, Labor Code, is
  amended by adding Sections 504.054 and 504.055 to read as follows:
         Sec. 504.054.  EXPEDITED PROVISION OF MEDICAL BENEFITS FOR
  INJURY SUSTAINED BY FIRST RESPONDER IN COURSE AND SCOPE OF
  EMPLOYMENT.  (a)  In this section, "first responder" means an
  individual employed by, or volunteering service to, a political
  subdivision of this state who is:
               (1)  a peace officer under Article 2.12, Code of
  Criminal Procedure;
               (2)  a person licensed under Chapter 773, Health and
  Safety Code, as an emergency care attendant, emergency medical
  technician, emergency medical technician-intermediate, emergency
  medical technician-paramedic, or licensed paramedic;
               (3)  a firefighter subject to certification by the
  Texas Commission on Fire Protection under Chapter 419, Government
  Code, whose principal duties are firefighting and aircraft crash
  and rescue;
               (4)  a volunteer firefighter, regardless of whether the
  volunteer firefighter is certified under Subchapter D, Chapter 419,
  Government Code; or
               (5)  an emergency medical services volunteer, as that
  term is defined by Section 773.003, Health and Safety Code.
         (a-1)  For purposes of this section, an injury sustained in
  the course and scope of employment includes an injury sustained by a
  first responder providing services on a volunteer basis.
         (b)  This section applies only to a first responder who
  sustains a serious injury, as defined by commissioner rule, in the
  course and scope of employment.
         (c)  The political subdivision, division, and insurance
  carrier shall accelerate and give priority to an injured first
  responder's claim for medical benefits, including all health care
  required to cure or relieve the effects naturally resulting from a
  compensable injury sustained in the course and scope of employment.
         (d)  The division shall accelerate, under rules adopted by
  the commissioner, a contested case hearing requested by or an
  appeal submitted by a first responder regarding the denial of a
  claim for medical benefits, including all health care required to
  cure or relieve the effects naturally resulting from a compensable
  injury sustained in the course and scope of employment.  The first
  responder shall provide notice to the division and independent
  review organization that the contested case or appeal involves a
  first responder.
         Sec. 504.055.  FIRST RESPONDER MEDICAL DISPUTES; CONTESTED
  CASE HEARING AND JUDICIAL REVIEW. (a)  In this section, "first
  responder" has the meaning assigned by Section 504.054.
         (b)  A first responder whose medical dispute remains
  unresolved after a review by an independent review organization is
  entitled to a contested case hearing.  The independent review
  organization's decision is binding during the pendency of a
  dispute.  A hearing under this subsection shall be conducted by the
  division in the same manner as a hearing conducted under Section
  413.0311.
         (c)  A first responder who has exhausted all administrative
  remedies under Subsection (b) and is aggrieved by a final decision
  of the division may seek judicial review of the decision.  Judicial
  review under this subsection shall be conducted in the manner
  provided by Section 413.0311(d).
         SECTION 40.  The following provisions of the Labor Code are
  repealed:
               (1)  Section 413.031(l);
               (2)  Sections 415.0035(c), (d), and (f);
               (3)  Section 415.0036(c);
               (4)  Section 415.004;
               (5)  Section 415.008(b); and
               (6)  Section 415.022.
         SECTION 41.  Sections 1305.355(e), (f), and (g), Insurance
  Code, as amended by this Act, and Section 1305.356, Insurance Code,
  as added by this Act, apply to a medical dispute based on a review by
  an independent review organization under Section 1305.355 that is
  commenced on or after June 1, 2012. A dispute based on a review by
  an independent review organization under Section 1305.355 that is
  commenced before June 1, 2012, is 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 42.  (a)  Section 402.073, Labor Code, as amended by
  this Act, applies only to an administrative hearing that is
  conducted on or after the effective date of this Act. An
  administrative hearing conducted before the effective date of this
  Act is governed by the law in effect when the hearing was conducted,
  and the former law is continued in effect for that purpose.
         (b)  The State Office of Administrative Hearings and the
  division of workers' compensation of the Texas Department of
  Insurance shall adopt an updated memorandum of understanding
  required by Section 402.073, Labor Code, as amended by this Act, not
  later than June 1, 2012.
         SECTION 43.  Section 403.001, Labor Code, as amended by this
  Act, and Section 403.008, Labor Code, as added by this Act, apply
  only to an administrative penalty assessed for an administrative
  violation that occurs on or after the effective date of this Act.
  An administrative penalty assessed for an administrative violation
  that occurred before the effective date of this Act is governed by
  the law in effect when the violation occurred, and the former law is
  continued in effect for that purpose.
         SECTION 44.  (a)  The commissioner of workers' compensation
  shall adopt the rules regarding certification of designated doctors
  required by Section 408.1225, Labor Code, as amended by this Act,
  not later than January 1, 2013.
         (b)  A designated doctor is not required to obtain
  certification under Section 408.1225, Labor Code, as amended by
  this Act, before January 1, 2013.
         (c)  Sections 408.1225(b), 413.044(b), and 413.0512(c),
  Labor Code, as amended by this Act, apply only to a disciplinary
  action taken against a designated doctor on or after January 1,
  2013. A disciplinary action taken against a designated doctor
  before that date is governed by the law as it existed immediately
  before the effective date of this Act, and the former law is
  continued in effect for that purpose.
         (d)  Section 408.0041, Labor Code, as amended by this Act,
  applies only to a medical examination by a designated doctor that
  occurs on or after January 1, 2013. A medical examination that
  occurs before that date is governed by the law in effect when the
  medical examination occurred, and the former law is continued in
  effect for that purpose.
         SECTION 45.  The change in law made by this Act in amending
  Sections 409.021, 415.0035, 415.008, 415.009, 415.010, 415.021,
  415.025, 415.032, 415.033, and 415.034, Labor Code, and Sections
  2051.151 and 2053.206, Insurance Code, adding Section 415.0211,
  Labor Code, and repealing Sections 415.0035(c), (d), and (f),
  415.0036(c), 415.004, 415.008(b), and 415.022, Labor Code, applies
  only to an administrative violation that occurs on or after the
  effective date of this Act. An administrative violation that
  occurs before the effective date of this Act is governed by the law
  in effect on the date the violation occurred, and the former law is
  continued in effect for that purpose.
         SECTION 46.  Sections 410.023 and 410.028, Labor Code, as
  amended by this Act, apply only to a benefit review conference
  requested on or after the effective date of this Act.  A benefit
  review conference requested before the effective date of this Act
  is 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 47.  Sections 413.031(k) and (k-1) and 413.0311(a),
  Labor Code, as amended by this Act, and Section 413.0312, Labor
  Code, as added by this Act, apply only to the appeal of a medical fee
  dispute under those sections that is based on a review conducted by
  the division of workers' compensation of the Texas Department of
  Insurance on or after June 1, 2012. The appeal of a medical fee
  dispute that is based on a review conducted by the division of
  workers' compensation before June 1, 2012, is 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 48.  Section 414.005, Labor Code, as amended by this
  Act, applies only to an investigation or review conducted on or
  after the effective date of this Act. An investigation or review
  conducted before the effective date of this Act is governed by the
  law in effect when the investigation or review was conducted, and
  the former law is continued in effect for that purpose.
         SECTION 49.  Section 415.036, Labor Code, as added by this
  Act, applies only to an order of the commissioner of workers'
  compensation issued on or after the effective date of this Act. An
  order of the commissioner that was issued before the effective date
  of this Act is governed by the law in effect when the order was
  issued, and the former law is continued in effect for that purpose.
         SECTION 50.  Sections 504.054 and 504.055, Labor Code, as
  added by this Act, apply only to a claim for workers' compensation
  benefits based on a compensable injury that occurs on or after the
  effective date of this Act. A claim based on a compensable injury
  that occurs before that date is governed by the law in effect on the
  date the compensable injury occurred, and the former law is
  continued in effect for that purpose.
         SECTION 51.  This Act takes effect September 1, 2011.