88R9035 SCL/BEE-F
 
  By: Bonnen H.B. No. 4343
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit plan preauthorization requirements for
  certain health care services and the direction of utilization
  review by physicians.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 4201.152, Insurance Code, is amended to
  read as follows:
         Sec. 4201.152.  UTILIZATION REVIEW UNDER DIRECTION OF
  PHYSICIAN.  A utilization review agent shall conduct utilization
  review under the direction of a physician licensed to practice
  medicine in this state.  The physician may not hold a license to
  practice administrative medicine under Section 155.009,
  Occupations Code.
         SECTION 2.  Subchapter M, Chapter 4201, Insurance Code, is
  amended by adding Section 4201.6015 to read as follows:
         Sec. 4201.6015.  INQUIRY BY TEXAS MEDICAL BOARD. (a)  If the
  Texas Medical Board believes that a physician has directed a
  utilization review in an arbitrary manner or without a medical
  basis or receives a complaint with that allegation, the Texas
  Medical Board:
               (1)  shall notify the physician of the allegation; and
               (2)  may compel the production of documents or other
  information as necessary to determine whether the utilization
  review was directed in an arbitrary manner or without a medical
  basis.
         (b)  An inquiry and determination under this section is
  limited to whether the utilization review was directed in an
  arbitrary manner or without a medical basis in accordance with the
  standards of medical practice. If the commissioner initiates a
  proceeding under Section 4201.601 in relation to the same
  utilization review for which the inquiry is being conducted, the
  Texas Medical Board shall suspend the inquiry until the conclusion
  of the commissioner's proceeding.
         SECTION 3.  The heading to Section 4201.602, Insurance Code,
  is amended to read as follows:
         Sec. 4201.602.  ENFORCEMENT PROCEEDINGS [PROCEEDING].
         SECTION 4.  Section 4201.602(a), Insurance Code, is amended
  to read as follows:
         (a)  The commissioner may initiate a proceeding under
  Section 4201.601 [this subchapter]. The Texas Medical Board may
  initiate a proceeding under Section 4201.6015.
         SECTION 5.  Section 4201.603, Insurance Code, is amended to
  read as follows:
         Sec. 4201.603.  REMEDIES AND PENALTIES; EMERGENCY REMEDIES
  [FOR VIOLATION].  (a) If the commissioner determines that a
  utilization review agent, health maintenance organization,
  insurer, or other person or entity conducting utilization review
  has violated or is violating this chapter, the commissioner may:
               (1)  impose a sanction under Chapter 82;
               (2)  issue a cease and desist order under Chapter 83; or
               (3)  assess an administrative penalty under Chapter 84.
         (b)  The Texas Medical Board may restrict, suspend, or revoke
  the license of a physician the board determines has directed a
  utilization review in an arbitrary manner or without a medical
  basis at the conclusion of a proceeding conducted under Section
  4201.6015.
         (c)  If a utilization review results in the serious injury or
  death of the individual who is the subject of the review, the
  commissioner may temporarily prohibit a physician who directed the
  review from directing utilization review and the Texas Medical
  Board may temporarily suspend the physician's license.  The
  commissioner or Texas Medical Board, as applicable, shall conduct a
  proceeding under Section 4201.601 or 4201.6015, as applicable,
  regarding the utilization review, and the prohibition or suspension
  is effective until the conclusion of the proceeding.
         SECTION 6.  Section 4201.653(d), Insurance Code, is amended
  to read as follows:
         (d)  To qualify for an exemption under Subsection (a), a [A]
  physician or provider is not required to:
               (1)  request the [an] exemption; or
               (2)  perform the health care service that is the
  subject of the exemption a minimum number of times [under
  Subsection (a) to qualify for the exemption].
         SECTION 7.  Section 4201.655, Insurance Code, is amended by
  amending Subsection (b) and adding Subsection (b-1) to read as
  follows:
         (b)  A determination made under Subsection (a)(2) must be
  made by an individual licensed to practice medicine in this state.  
  For a determination made under Subsection (a)(2) with respect to a
  physician, the determination must be made by an individual licensed
  to practice medicine in this state who has the same or similar
  specialty as that physician.  The reviewing physician may not hold a
  license to practice administrative medicine under Section 155.009,
  Occupations Code.
         (b-1)  Notwithstanding Subsection (a)(2), if there are fewer
  than five claims submitted by the physician or provider during the
  most recent evaluation period described by Section 4201.653(b) for
  a particular health care service, the health maintenance
  organization or insurer shall review all the claims submitted by
  the physician or provider during the most recent evaluation period
  for that service.
         SECTION 8.  Section 4201.656(a), Insurance Code, is amended
  to read as follows:
         (a)  A physician or provider has a right to a review of an
  adverse determination regarding a preauthorization exemption,
  including a health maintenance organization's or insurer's
  determination to deny an exemption to the physician or provider
  under Section 4201.653, be conducted by an independent review
  organization. A health maintenance organization or insurer may not
  require a physician or provider to engage in an internal appeal
  process before requesting a review by an independent review
  organization under this section.
         SECTION 9.  Sections 4201.659(b) and (c), Insurance Code,
  are amended to read as follows:
         (b)  Regardless of whether an exemption is rescinded after
  the provision of a health care service subject to the exemption, a
  [A] health maintenance organization or an insurer may not conduct a
  utilization [retrospective] review or require another review
  similar to preauthorization of the [a health care] service [subject
  to an exemption] except:
               (1)  to determine if the physician or provider still
  qualifies for an exemption under this subchapter; or
               (2)  if the health maintenance organization or insurer
  has a reasonable cause to suspect a basis for denial exists under
  Subsection (a).
         (c)  For a utilization [retrospective] review described by
  Subsection (b)(2), nothing in this subchapter may be construed to
  modify or otherwise affect:
               (1)  the requirements under or application of Section
  4201.305, including any timeframes specified by that section; or
               (2)  any other applicable law, except to prescribe the
  only circumstances under which:
                     (A)  a [retrospective] utilization review may
  occur as specified by Subsection (b)(2); or
                     (B)  payment may be denied or reduced as specified
  by Subsection (a).
         SECTION 10.  Subchapter N, Chapter 4201, Insurance Code, is
  amended by adding Section 4201.660 to read as follows:
         Sec. 4201.660.  REPORT. Each health maintenance
  organization and insurer shall submit to the department, in the
  form and manner prescribed by the commissioner, an annual written
  report, for each health care service subject to an exemption under
  Section 4201.653, on the:
               (1)  exemptions granted by the health maintenance
  organization or insurer for the service; and
               (2)  determinations by the health maintenance
  organization or insurer to rescind or deny an exemption for the
  service.
         SECTION 11.  Section 151.002(a)(13), Occupations Code, is
  amended to read as follows:
               (13)  "Practicing medicine" means:
                     (A)  the diagnosis, treatment, or offer to treat a
  mental or physical disease or disorder or a physical deformity or
  injury by any system or method, or the attempt to effect cures of
  those conditions, by a person who:
                           (i) [(A)]  publicly professes to be a
  physician or surgeon; or
                           (ii) [(B)] directly or indirectly charges
  money or other compensation for those services; and
                     (B)  the direction of utilization review
  conducted by a utilization review agent under Section 4201.152,
  Insurance Code.
         SECTION 12.  The change in law made by this Act applies only
  to utilization review conducted on or after the effective date of
  this Act. Utilization review conducted before the effective date of
  this Act is governed by the law as it existed immediately before the
  effective date of this Act, and that law is continued in effect for
  that purpose.
         SECTION 13.  This Act takes effect September 1, 2023.