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A BILL TO BE ENTITLED
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AN ACT
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relating to conduct of insurers providing preferred provider |
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benefit plans with respect to physician and health care provider |
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contracts and claims. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Sections 1301.066 and 1301.103, Insurance Code, |
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are amended to read as follows: |
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Sec. 1301.066. RETALIATION AGAINST PREFERRED PROVIDER |
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PROHIBITED. (a) An insurer may not engage in any retaliatory action |
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against a physician or health care provider[, including terminating |
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the physician's or provider's participation in the preferred |
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provider benefit plan or refusing to renew the physician's or |
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provider's contract,] because the physician or provider has: |
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(1) on behalf of an insured, reasonably filed a |
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complaint against the insurer; or |
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(2) appealed a decision of the insurer. |
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(b) A retaliatory action under Subsection (a) includes: |
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(1) terminating the physician's or provider's |
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participation in the preferred provider benefit plan; |
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(2) refusing to renew the physician's or provider's |
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contract; |
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(3) implementing measurable penalties in the contract |
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negotiation process; |
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(4) engaging in an unfair or deceptive practice, |
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including not listing the physician or provider in the network |
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directory or requiring the physician or provider to submit medical |
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records with each claim; |
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(5) arbitrarily reducing the physician's or provider's |
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fees on the insurer's fee schedule; and |
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(6) otherwise making changes to material contractual |
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terms that are adverse to the physician or provider. |
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(c) Subsections (b)(3)-(6) do not apply to a freestanding |
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emergency medical care facility. |
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Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. (a) |
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Except as provided by Sections 1301.104 and 1301.1054, not later |
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than the 45th day after the date an insurer receives a clean claim |
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from a preferred provider in a nonelectronic format or the 30th day |
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after the date an insurer receives a clean claim from a preferred |
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provider that is electronically submitted, the insurer shall make a |
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determination of whether the claim is payable and: |
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(1) if the insurer determines the entire claim is |
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payable, pay the total amount of the claim in accordance with the |
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contract between the preferred provider and the insurer; |
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(2) if the insurer determines a portion of the claim is |
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payable, pay the portion of the claim that is not in dispute and |
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notify the preferred provider in writing why the remaining portion |
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of the claim will not be paid; or |
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(3) if the insurer determines that the claim is not |
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payable, notify the preferred provider in writing why the claim |
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will not be paid. |
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(b) An insurer shall provide notice under Subsection (a) |
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electronically if the preferred provider's clean claim was |
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electronically submitted and the provider is not a freestanding |
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emergency medical care facility. |
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SECTION 2. Section 1301.105, Insurance Code, is amended by |
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amending Subsection (d) and adding Subsection (e) to read as |
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follows: |
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(d) If the preferred provider does not supply information |
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reasonably requested by the insurer in connection with the audit, |
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the insurer shall or, if the provider is a freestanding emergency |
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medical care facility, may: |
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(1) notify the provider in writing that the provider |
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must provide the information not later than the 45th day after the |
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date of the notice or forfeit the amount of the claim; and |
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(2) if the provider does not provide the information |
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required by this section, recover the amount of the claim. |
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(e) An insurer shall make a request or provide information |
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under this section electronically if the preferred provider's clean |
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claim was electronically submitted and the provider is not a |
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freestanding emergency medical care facility. |
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SECTION 3. Sections 1301.1051 and 1301.1052, Insurance |
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Code, are amended to read as follows: |
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Sec. 1301.1051. COMPLETION OF AUDIT. (a) The insurer must |
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complete an audit under Section 1301.105 on or before the 180th day |
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after the date the clean claim is received by the insurer, and any |
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additional payment due a preferred provider or any refund due the |
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insurer shall be made not later than the 30th day after the |
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completion of the audit. |
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(b) An insurer may not recover a payment on an audited claim |
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until a final audit is completed if the claim was submitted by a |
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preferred provider other than a freestanding emergency medical care |
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facility. |
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(c) An insurer shall provide written notice to the preferred |
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provider, other than a freestanding emergency medical care |
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facility, of the insurer's failure to complete an audit in the time |
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required by Subsection (a) not later than the 15th day after the |
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date on which the insurer is required to complete the audit under |
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that subsection. |
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Sec. 1301.1052. PREFERRED PROVIDER APPEAL AFTER AUDIT. (a) |
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If a preferred provider disagrees with a refund request made by an |
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insurer based on an audit under Section 1301.105, the insurer shall |
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provide the provider with an opportunity to appeal in accordance |
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with this section, and the insurer may not attempt to recover the |
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payment until all appeal rights are exhausted. |
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(b) An insurer shall provide a reasonable mechanism for an |
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appeal requested under Subsection (a) by a preferred provider other |
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than a freestanding emergency medical care facility. The review |
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mechanism must incorporate, in an advisory role only, a review |
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panel. |
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(c) A review panel described by Subsection (b) must be |
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composed of at least three preferred provider representatives of |
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the same or similar specialty as the affected preferred provider |
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selected by the insurer from a list of preferred providers. The |
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preferred providers contracting with the insurer in the applicable |
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service area shall provide the list of preferred provider |
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representatives to the insurer. |
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(d) On request and if applicable, the insurer shall provide |
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to the affected preferred provider: |
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(1) the panel's composition and recommendation; and |
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(2) a written explanation of the insurer's |
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determination, if that determination is contrary to the panel's |
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recommendation. |
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SECTION 4. Subchapter C, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.10525 to read as follows: |
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Sec. 1301.10525. DEPARTMENT REVIEW OF AUDITS. (a) The |
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commissioner by rule shall establish procedures for a preferred |
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provider, other than a freestanding emergency medical care |
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facility, to submit a request for the department to review an audit |
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conducted by an insurer under this subchapter. The department |
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review of an audit is a contested case under Chapter 2001, |
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Government Code. |
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(b) If the department determines that an audit for which a |
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preferred provider requested review under Subsection (a) resulted |
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in unreasonable costs for the preferred provider, unnecessarily |
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delayed or prevented payment of a claim, or otherwise violated this |
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subchapter or rules adopted under this subchapter, the department |
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shall: |
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(1) award compensatory damages to the preferred |
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provider incurred as a result of the audit; and |
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(2) order the insurer to pay to the department the |
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costs incurred by the department in reviewing the audit. |
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SECTION 5. Section 1301.132, Insurance Code, is amended by |
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adding Subsections (c), (d), and (e) to read as follows: |
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(c) An insurer shall provide a reasonable mechanism for an |
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appeal requested under Subsection (b) by a physician or health care |
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provider other than a freestanding emergency medical care facility. |
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The review mechanism must incorporate, in an advisory role only, a |
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review panel. |
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(d) A review panel described by Subsection (c) must be |
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composed of at least three preferred provider representatives of |
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the same or similar specialty as the affected preferred provider |
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selected by the insurer from a list of preferred providers. The |
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preferred providers contracting with the insurer in the applicable |
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service area shall provide the list of preferred provider |
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representatives to the insurer. |
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(e) On request and if applicable, the insurer shall provide |
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to the affected preferred provider: |
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(1) the panel's composition and recommendation; and |
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(2) a written explanation of the insurer's |
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determination, if that determination is contrary to the panel's |
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recommendation. |
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SECTION 6. (a) The changes in law made by this Act apply to |
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a claim for payment made on or after the effective date of this Act |
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unless the claim is made under a contract that was entered into |
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before the effective date of this Act and that, at the time the |
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claim is made, has not been renewed or was last renewed before the |
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effective date of this Act. |
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(b) A claim made before the effective date of this Act or |
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made on or after the effective date of this Act under a contract |
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described by Subsection (a) of this section is governed by the law |
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as it existed immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 7. This Act takes effect September 1, 2023. |