83R2664 KKR-D

By: Kolkhorst H.B. No. 1761

A BILL TO BE ENTITLED

AN ACT

relating to the consideration of strategies by the Health and Human Services Commission to ensure the appropriate use of diagnostic ancillary services in the Medicaid program.

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

SECTION 1. Subchapter B, Chapter 531, Government Code, is amended by adding Section 531.024162 to read as follows:

Sec. 531.024162. STRATEGIES TO ENSURE APPROPRIATE USE OF DIAGNOSTIC ANCILLARY SERVICES. (a) The commission shall:

(1) adopt new cost-effective strategies to ensure the appropriate use of diagnostic ancillary services in the Medicaid program; and

(2) strengthen existing methods to reduce the use of unnecessary diagnostic ancillary services in the Medicaid program.

(b) When considering the adoption of new cost-effective strategies to ensure the appropriate use of diagnostic ancillary services in the Medicaid program, the commission shall examine implementing within the Medicaid fee-for-service model and the STAR and STAR + PLUS Medicaid managed care programs a prior notification program in which:

(1) outlier health care providers' use of diagnostic ancillary services are compared to evidence-based clinical guidelines; and

(2) health care providers are educated about the appropriate use of diagnostic ancillary services.

(c) When considering strengthening existing methods to reduce the use of unnecessary diagnostic ancillary services in the Medicaid program, the commission shall examine:

(1) requiring every STAR and STAR + PLUS Medicaid managed care program to implement a prior authorization program; and

(2) modifying the existing prior authorization programs within the Medicaid fee-for-service model and the STAR and STAR + PLUS Medicaid managed care programs so that:

(A) the programs target health care providers who order significantly more diagnostic ancillary services than other providers who treat similar patients;

(B) outlier providers who order diagnostic ancillary services inappropriately are required to participate in the programs; and

(C) the programs are expanded to include additional types of diagnostic ancillary services that account for a significant share of spending, have evidence-based standards for appropriate use, and exhibit variations in use among providers and geographic areas.

(d) The commission shall examine options within the Medicaid fee-for-service model and the STAR and STAR + PLUS Medicaid managed care programs to improve payment accuracy for diagnostic ancillary services and to reduce the financial incentive for a health care provider to order unnecessary diagnostic ancillary services to be performed at a facility in which the provider has a financial interest. Options the commission shall examine under this subsection and may consider implementing include:

(1) accounting for duplications in the work of a provider and the expenses relating to that work that occur when two or more diagnostic ancillary services are provided at the same time by:

(A) combining into a single payment rate or comprehensive code multiple discrete diagnostic ancillary services that are often provided at the same time by the same provider; or

(B) reducing the payment rate for subsequent diagnostic ancillary services that are provided to a patient at the same time by the same provider; and

(2) reducing the payment rates for certain diagnostic ancillary services that are ordered and provided by the same provider.

(e) The commission shall review strategies recommended by the federal Medicare Payment Advisory Commission during fiscal year 2011 to reduce the use of unnecessary diagnostic ancillary services in the Medicare program and consider adopting those strategies for the Medicaid program.

(f) The commission shall identify cost-effective strategies used by STAR and STAR + PLUS Medicaid managed care programs to reduce the use of unnecessary diagnostic ancillary services and consider:

(1) implementing those strategies within the Medicaid fee-for-service model; and

(2) requiring the use of those strategies in other STAR and STAR + PLUS Medicaid managed care programs.

SECTION 2. If before implementing any provision of this Act a state agency determines that a waiver or authorization from a federal agency is necessary for implementation of that provision, the agency affected by the provision shall request the waiver or authorization and may delay implementing that provision until the waiver or authorization is granted.

SECTION 3. This Act takes effect immediately if it receives a vote of two-thirds of all the members elected to each house, as provided by Section 39, Article III, Texas Constitution. If this Act does not receive the vote necessary for immediate effect, this Act takes effect September 1, 2013.