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A BILL TO BE ENTITLED
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AN ACT
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relating to the use of extrapolation by a health maintenance |
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organization or an insurer to audit claims. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.340, Insurance Code, is amended by |
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adding Subsections (f) and (g) to read as follows: |
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(f) A health maintenance organization may not use |
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extrapolation to complete an audit of a participating physician or |
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provider. Any additional payment due a participating physician or |
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provider or any refund due the health maintenance organization must |
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be based on the actual overpayment or underpayment and may not be |
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based on an extrapolation. |
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(g) In this section, "extrapolation" means a mathematical |
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process or technique used by a health maintenance organization in |
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the audit of a participating physician or provider to estimate |
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audit results or findings for a larger batch or group of claims not |
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reviewed by the health maintenance organization. |
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SECTION 2. Section 1301.105, Insurance Code, is amended by |
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adding Subsections (e) and (f) to read as follows: |
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(e) An insurer may not use extrapolation to complete an |
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audit of a preferred provider. Any additional payment due a |
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preferred provider or any refund due the insurer must be based on |
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the actual overpayment or underpayment and may not be based on an |
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extrapolation. |
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(f) In this section, "extrapolation" means a mathematical |
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process or technique used by an insurer in the audit of a preferred |
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provider to estimate audit results or findings for a larger batch or |
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group of claims not reviewed by the insurer. |
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SECTION 3. The change in law made by this Act applies only |
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to the audit of a physician or provider under a contract with an |
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insurer or health maintenance organization entered into or renewed |
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on or after the effective date of this Act. |
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SECTION 4. This Act takes effect September 1, 2017. |