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A BILL TO BE ENTITLED
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AN ACT
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relating to the direction of utilization review by physicians. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 4201.152, Insurance Code, is amended to |
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read as follows: |
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Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF |
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PHYSICIAN. A utilization review agent shall conduct utilization |
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review under the direction of a physician licensed to practice |
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medicine in this state. The physician may not hold a license to |
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practice administrative medicine under Section 155.009, |
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Occupations Code. |
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SECTION 2. Subchapter M, Chapter 4201, Insurance Code, is |
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amended by adding Section 4201.6015 to read as follows: |
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Sec. 4201.6015. INQUIRY BY TEXAS MEDICAL BOARD. (a) If the |
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Texas Medical Board believes that a physician has directed a |
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utilization review in an arbitrary manner or without a medical |
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basis or receives a complaint with that allegation, the Texas |
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Medical Board: |
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(1) shall notify the physician of the allegation; and |
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(2) may compel the production of documents or other |
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information as necessary to determine whether the utilization |
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review was directed in an arbitrary manner or without a medical |
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basis. |
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(b) An inquiry and determination under this section is |
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limited to whether the utilization review was directed in an |
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arbitrary manner or without a medical basis in accordance with the |
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standards of medical practice. If the commissioner initiates a |
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proceeding under Section 4201.601 in relation to the same |
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utilization review for which the inquiry is being conducted, the |
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Texas Medical Board shall suspend the inquiry until the conclusion |
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of the commissioner's proceeding. |
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SECTION 3. The heading to Section 4201.602, Insurance Code, |
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is amended to read as follows: |
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Sec. 4201.602. ENFORCEMENT PROCEEDINGS [PROCEEDING]. |
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SECTION 4. Section 4201.602(a), Insurance Code, is amended |
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to read as follows: |
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(a) The commissioner may initiate a proceeding under |
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Section 4201.601 [this subchapter]. The Texas Medical Board may |
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initiate a proceeding under Section 4201.6015. |
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SECTION 5. Section 4201.603, Insurance Code, is amended to |
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read as follows: |
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Sec. 4201.603. REMEDIES AND PENALTIES; EMERGENCY REMEDIES |
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[FOR VIOLATION]. (a) If the commissioner determines that a |
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utilization review agent, health maintenance organization, |
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insurer, or other person or entity conducting utilization review |
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has violated or is violating this chapter, the commissioner may: |
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(1) impose a sanction under Chapter 82; |
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(2) issue a cease and desist order under Chapter 83; or |
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(3) assess an administrative penalty under Chapter 84. |
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(b) The Texas Medical Board may restrict, suspend, or revoke |
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the license of a physician the board determines has directed a |
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utilization review in an arbitrary manner or without a medical |
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basis at the conclusion of a proceeding conducted under Section |
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4201.6015. |
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(c) If a utilization review results in the serious injury or |
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death of the individual who is the subject of the review, the |
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commissioner may temporarily prohibit a physician who directed the |
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review from directing utilization review and the Texas Medical |
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Board may temporarily suspend the physician's license. The |
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commissioner or Texas Medical Board, as applicable, shall conduct a |
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proceeding under Section 4201.601 or 4201.6015, as applicable, |
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regarding the utilization review, and the prohibition or suspension |
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is effective until the conclusion of the proceeding. |
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SECTION 6. Section 151.002(a)(13), Occupations Code, is |
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amended to read as follows: |
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(13) "Practicing medicine" means: |
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(A) the diagnosis, treatment, or offer to treat a |
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mental or physical disease or disorder or a physical deformity or |
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injury by any system or method, or the attempt to effect cures of |
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those conditions, by a person who: |
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(i) [(A)] publicly professes to be a |
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physician or surgeon; or |
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(ii) [(B)] directly or indirectly charges |
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money or other compensation for those services; and |
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(B) the direction of utilization review |
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conducted by a utilization review agent under Section 4201.152, |
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Insurance Code. |
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SECTION 7. The change in law made by this Act applies only |
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to utilization review conducted on or after the effective date of |
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this Act. Utilization review conducted before the effective date of |
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this Act is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 8. This Act takes effect September 1, 2023. |