BILL ANALYSIS |
C.S.H.B. 1649 |
By: Muņoz, Jr. |
Insurance |
Committee Report (Substituted) |
BACKGROUND AND PURPOSE
Interested parties contend that the practice under which a health insurer or health maintenance organization extrapolates findings of a claims audit across the entirety of a provider's recent claims history and then seeks recoupment of overpayments based on that extrapolation places an unjust burden on the provider. C.S.H.B. 1649 seeks to prevent abusive claims audit behavior by prohibiting certain insurers and health maintenance organizations from using extrapolation to complete an audit of a preferred provider or of a participating physician or provider, respectively.
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CRIMINAL JUSTICE IMPACT
It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.
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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.
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ANALYSIS
C.S.H.B. 1649 amends the Insurance Code to prohibit a health maintenance organization and an insurer authorized to issue, deliver, or issue for delivery health insurance policies from using extrapolation to complete an audit of a physician or provider participating in the health maintenance organization or of a preferred provider of the insurer, respectively. The bill requires any additional payment due such a physician or provider or any refund due the health maintenance organization or insurer, as applicable, to be based on the actual overpayment or underpayment and prohibits any such additional payment or refund from being based on an extrapolation. The bill makes its provisions prohibiting the use of extrapolation by a health maintenance organization inapplicable to coverage under the child health plan program, a health benefits plan for certain children, or a Medicaid program.
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EFFECTIVE DATE
September 1, 2017.
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COMPARISON OF ORIGINAL AND SUBSTITUTE
While C.S.H.B. 1649 may differ from the original in minor or nonsubstantive ways, the following comparison is organized and formatted in a manner that indicates the substantial differences between the introduced and committee substitute versions of the bill.
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