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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan preauthorization requirements for |
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certain health care services and the direction of utilization |
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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 4201.653(d), Insurance Code, is amended |
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to read as follows: |
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(d) To qualify for an exemption under Subsection (a), a [A] |
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physician or provider is not required to: |
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(1) request the [an] exemption; or |
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(2) perform the health care service that is the |
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subject of the exemption a minimum number of times [under |
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Subsection (a) to qualify for the exemption]. |
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SECTION 7. Section 4201.655, Insurance Code, is amended by |
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amending Subsection (b) and adding Subsection (b-1) to read as |
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follows: |
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(b) A determination made under Subsection (a)(2) must be |
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made by an individual licensed to practice medicine in this state. |
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For a determination made under Subsection (a)(2) with respect to a |
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physician, the determination must be made by an individual licensed |
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to practice medicine in this state who has the same or similar |
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specialty as that physician. The reviewing physician may not hold a |
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license to practice administrative medicine under Section 155.009, |
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Occupations Code. |
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(b-1) Notwithstanding Subsection (a)(2), if there are fewer |
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than five claims submitted by the physician or provider during the |
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most recent evaluation period described by Section 4201.653(b) for |
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a particular health care service, the health maintenance |
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organization or insurer shall review all the claims submitted by |
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the physician or provider during the most recent evaluation period |
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for that service. |
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SECTION 8. Section 4201.656(a), Insurance Code, is amended |
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to read as follows: |
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(a) A physician or provider has a right to a review of an |
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adverse determination regarding a preauthorization exemption, |
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including a health maintenance organization's or insurer's |
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determination to deny an exemption to the physician or provider |
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under Section 4201.653, be conducted by an independent review |
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organization. A health maintenance organization or insurer may not |
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require a physician or provider to engage in an internal appeal |
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process before requesting a review by an independent review |
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organization under this section. |
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SECTION 9. Sections 4201.659(b) and (c), Insurance Code, |
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are amended to read as follows: |
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(b) Regardless of whether an exemption is rescinded after |
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the provision of a health care service subject to the exemption, a |
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[A] health maintenance organization or an insurer may not conduct a |
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utilization [retrospective] review or require another review |
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similar to preauthorization of the [a health care] service [subject |
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to an exemption] except: |
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(1) to determine if the physician or provider still |
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qualifies for an exemption under this subchapter; or |
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(2) if the health maintenance organization or insurer |
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has a reasonable cause to suspect a basis for denial exists under |
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Subsection (a). |
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(c) For a utilization [retrospective] review described by |
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Subsection (b)(2), nothing in this subchapter may be construed to |
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modify or otherwise affect: |
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(1) the requirements under or application of Section |
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4201.305, including any timeframes specified by that section; or |
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(2) any other applicable law, except to prescribe the |
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only circumstances under which: |
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(A) a [retrospective] utilization review may |
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occur as specified by Subsection (b)(2); or |
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(B) payment may be denied or reduced as specified |
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by Subsection (a). |
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SECTION 10. Subchapter N, Chapter 4201, Insurance Code, is |
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amended by adding Section 4201.660 to read as follows: |
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Sec. 4201.660. REPORT. Each health maintenance |
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organization and insurer shall submit to the department, in the |
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form and manner prescribed by the commissioner, an annual written |
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report, for each health care service subject to an exemption under |
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Section 4201.653, on the: |
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(1) exemptions granted by the health maintenance |
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organization or insurer for the service; and |
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(2) determinations by the health maintenance |
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organization or insurer to rescind or deny an exemption for the |
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service. |
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SECTION 11. 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 12. 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 13. This Act takes effect September 1, 2023. |