|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to payment for services provided by certain physicians and |
|
health care providers to individuals covered by managed care plans. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Subchapter A, Chapter 1467, Insurance Code, is |
|
amended by adding Section 1467.0021 to read as follows: |
|
Sec. 1467.0021. CERTAIN CLAIMS EXCLUDED. This chapter does |
|
not apply to a claim with respect to services to which Chapter 1468 |
|
applies. |
|
SECTION 2. Subtitle F, Title 8, Insurance Code, is amended |
|
by adding Chapter 1468 to read as follows: |
|
CHAPTER 1468. PAYMENT OF CERTAIN SERVICES PROVIDED TO INDIVIDUAL |
|
COVERED BY MANAGED CARE PLAN |
|
Sec. 1468.001. DEFINITIONS. In this chapter: |
|
(1) "Facility-based physician" means a radiologist, |
|
an anesthesiologist, a pathologist, an emergency department |
|
physician, or a neonatologist: |
|
(A) to whom the facility has granted clinical |
|
privileges; and |
|
(B) who provides services to patients of the |
|
facility under those clinical privileges. |
|
(2) "Managed care plan" means a plan under which a |
|
health maintenance organization, preferred provider benefit plan |
|
issuer, or other organization provides or arranges for health care |
|
benefits to plan enrollees and requires or encourages plan |
|
enrollees to use health care practitioners and health care |
|
facilities designated by the plan. |
|
Sec. 1468.002. APPLICABILITY OF CHAPTER. This chapter |
|
applies to: |
|
(1) emergency medical services provided by an |
|
out-of-network provider; and |
|
(2) medical or health care services provided: |
|
(A) to an individual covered by a managed care |
|
plan; |
|
(B) within a hospital or similar facility; and |
|
(C) by a facility-based physician or provider who |
|
is an out-of-network provider. |
|
Sec. 1468.003. PAYMENT FROM MANAGED CARE PLAN: USUAL AND |
|
CUSTOMARY CHARGE. A physician or health care provider who provides |
|
a medical or health care service described by Section 1468.002 to an |
|
individual covered for the service under a managed care plan is |
|
entitled to payment from the individual's managed care plan in an |
|
amount equal to the usual and customary charge for the service, |
|
minus any deductible, copayment, or coinsurance for which the |
|
individual is responsible under the plan. |
|
Sec. 1468.004. ARBITRATION OF USUAL AND CUSTOMARY CHARGE. |
|
If a physician or health care provider and a managed care plan |
|
issuer do not agree on the usual and customary charge for a medical |
|
or health care service that is subject to this chapter, the |
|
physician or health care provider or the managed care plan issuer |
|
may submit the dispute to arbitration to determine the usual and |
|
customary charge. |
|
Sec. 1468.005. ARBITRATION PROCEDURES; ARBITRATOR |
|
QUALIFICATIONS. (a) The commissioner by rule shall: |
|
(1) establish procedures for conducting an |
|
arbitration under this chapter; and |
|
(2) prescribe qualifications for serving as an |
|
arbitrator under this chapter. |
|
(b) The department shall maintain a list of arbitrators |
|
qualified to conduct arbitrations under this chapter. |
|
Sec. 1468.006. APPEAL OF ARBITRATOR DETERMINATION. (a) On |
|
or before the 60th day after the date an arbitrator determines a |
|
usual and customary charge under this chapter, either party to the |
|
arbitration may file a petition for judicial review of the |
|
determination in a district court. |
|
(b) The standard of review for judicial review under this |
|
section is de novo. |
|
(c) In an action under this section, the amount determined |
|
by the arbitrator to be the usual and customary charge shall be |
|
admitted into evidence. There is a rebuttable presumption that the |
|
amount determined by the arbitrator is the usual and customary |
|
charge. |
|
(d) The party that prevails in an action under this section |
|
is entitled to an award of the party's reasonable attorney's fees |
|
incurred in connection with the action. |
|
(e) The managed care plan shall promptly pay the physician |
|
or provider the amount of the usual and customary charge determined |
|
by the court under this section. |
|
Sec. 1468.007. APPLICABILITY OF CERTAIN OTHER LAW. Except |
|
to the extent of any conflict with this section, Chapter 171, Civil |
|
Practice and Remedies Code, applies to an arbitration conducted |
|
under this chapter. |
|
Sec. 1468.008. PAYMENT FROM COVERED INDIVIDUAL. (a) Unless |
|
an individual who receives a medical or health care service to which |
|
this chapter applies agrees before the service is provided to a |
|
total charge for the service that exceeds the usual and customary |
|
charge, the physician or provider is not entitled to payment from |
|
the individual in excess of any required deductible, copayment, or |
|
coinsurance. |
|
(b) If the physician or provider seeks to recover from the |
|
individual an amount that exceeds the amount allowed under this |
|
section, the physician or provider must: |
|
(1) notify the individual of the usual and customary |
|
rate established in accordance with this chapter; and |
|
(2) notify the individual that the individual is not |
|
required by law to pay the portion of the fee that exceeds the usual |
|
and customary rate unless the individual agreed to a higher rate |
|
before the service was provided. |
|
(c) If a physician or provider bills an individual in |
|
violation of this section and the individual pays an amount that is |
|
higher than the individual would be required to pay under this |
|
section, the individual may file an action against the physician or |
|
provider to recover the amount of the overpayment and the |
|
individual's reasonable attorney's fees incurred in connection with |
|
recovering the overpayment. |
|
(d) If a physician or health care provider files an action |
|
against an individual to recover payment for services that are |
|
subject to this chapter and is found to be seeking payment that |
|
exceeds the amount for which the individual is liable under this |
|
section, the individual is entitled to recover the individual's |
|
reasonable attorney's fees incurred in connection with the action. |
|
SECTION 3. The change in law made by this Act applies only |
|
to medical or health care services provided on or after the |
|
effective date of this Act to an individual covered under a managed |
|
care plan delivered, issued for delivery, or renewed on or after the |
|
effective date of this Act and payment for those services. |
|
SECTION 4. This Act takes effect January 1, 2012. |