81R32396 E
By: Smithee H.B. No. 4183
Substitute the following for H.B. No. 4183:
By: Thompson C.S.H.B. No. 4183
A BILL TO BE ENTITLED
AN ACT
relating to billing practices for certain health care facilities
and providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 324.001, Health and Safety Code, is
amended by adding Subdivision (8) to read as follows:
(8) "Preferred provider" means a facility that
contracts to provide medical care or health care to participants or
beneficiaries of a health plan in accordance with agreed
reimbursement rates.
SECTION 2. Section 324.101, Health and Safety Code, is
amended by amending Subsections (e) and (f) and adding Subsections
(f-1), (f-2), (f-3), (f-4), (f-5), and (f-6) to read as follows:
(e) A facility shall provide to the consumer at the
consumer's request an itemized statement of the billed charges
[services] if the consumer requests the statement not later than
the first anniversary of the date the person is discharged from the
facility. The facility shall provide the statement to the consumer
not later than the 10th business day after the date on which the
statement is requested. The facility may provide the consumer with
an electronic copy of the itemized statement.
(f) If the billed charges exceed $10,000, the [A] facility
shall provide an itemized statement of the billed charges
[services] to a third-party payor who is actually or potentially
responsible for paying all or part of the billed charges for
providing services [provided] to a patient [and who has received a
claim for payment of those services. To be entitled to receive a
statement, the third-party payor must request the statement from
the facility and must have received a claim for payment. The
request must be made not later than one year after the date on which
the payor received the claim for payment]. The facility shall
provide the statement to the payor with the facility's claim for
payment.
(f-1) A third-party payor may request an itemized statement
for billed charges of $10,000 or less.
(f-2) A third-party payor may request additional
information, including medical records and operative reports,
relating to a claim that has been submitted for payment to the
third-party payor.
(f-3) The facility shall provide the itemized statement
requested under Subsection (f-1) or the information requested under
Subsection (f-2) as soon as practicable. The days between the date
a third-party payor requests the itemized statement or additional
information from the facility and the date the payor receives the
itemized statement or information may not be counted in a payment
period established by statute or under contract.
(f-4) The facility may provide the third-party payor with an
electronic copy of an itemized statement under this section [not
later than the 30th day after the date on which the payor requests
the statement].
(f-5) If a third-party payor receives a claim for payment of
part [but not all] of the billed charges [services], the
third-party payor is entitled to [may request] an itemized
statement of only the billed charges [services] for which payment
is claimed or to which any deduction or copayment applies.
(f-6) A third-party payor that requests an itemized
statement under Subsection (f-1) or additional information under
Subsection (f-2) must have evidence sufficient to prove the date
the payor made the request, which may include a certified mail
receipt or an electronic date stamp. Unless rebutted by sufficient
evidence provided by a facility, the date the payor receives the
itemized statement or additional information, as shown in the
payor's records, is presumed to be the date of receipt for purposes
of Subsection (f-3).
SECTION 3. Section 324.103, Health and Safety Code, is
amended to read as follows:
Sec. 324.103. [CONSUMER] WAIVER PROHIBITED. The
provisions of this chapter may not be waived, voided, or nullified
by a contract or an agreement between a facility and a consumer or
third-party payor.
SECTION 4. Subchapter C, Chapter 324, Health and Safety
Code, is amended by adding Sections 324.104, 324.105, 324.106, and
324.107 to read as follows:
Sec. 324.104. CLAIM FOR PAYMENT FROM PREFERRED PROVIDER.
(a) A preferred provider that directly or through its agent or
assignee asserts that a claim for payment of a medical or health
care service or supply provided to a consumer, including a claim for
payment of the amount due for a disallowed discount on the service
or supply provided, has not been timely or accurately paid shall
provide written notification of the nonpayment or inaccuracy to the
third-party payor not later than the first anniversary of the
earlier of the date the preferred provider received payment from
the payor or the date that payment was due. A preferred provider or
agent that fails to provide the notification before that date is
barred from asserting the claim of nonpayment or inaccuracy. The
notice required by this subsection does not affect a statute of
limitations applicable to a claim.
(b) If a patient is admitted to a preferred provider for
more than 30 days, the preferred provider on request of a
third-party payor shall provide an interim statement of the
facility's billed charges to the third-party payor not later than
the 10th day after the date the third-party payor submits the
request.
Sec. 324.105. OVERPAYMENT AND REIMBURSEMENT. (a) A
third-party payor may recover an overpayment to a preferred
provider if:
(1) not later than the 180th day after the date the
provider receives the payment, the payor provides written notice of
the overpayment to the provider that includes the basis and
specific reasons for the request for recovery of funds; and
(2) the provider does not make arrangements for
repayment of the requested funds on or before the 45th day after the
date the provider receives the notice.
(b) A third-party payor that fails to provide notice of
overpayment by the 180th day after the date the preferred provider
receives a payment on a claim is barred from recovering an
overpayment on that claim.
(c) If a preferred provider disagrees with a request for
recovery of an overpayment, the third-party payor shall allow the
provider an opportunity to appeal, and the payor may not attempt to
recover the overpayment until all appeal rights are exhausted.
(d) A preferred provider that fails to make a reimbursement
required by this section shall pay, in addition to the
reimbursement, a late penalty in an amount equal to 10 percent of
the amount of the required reimbursement.
Sec. 324.106. APPLICABILITY TO ENTITIES CONTRACTING WITH
PREFERRED PROVIDER OR THIRD-PARTY PAYOR. This subchapter applies
to a person with whom:
(1) a preferred provider contracts to submit or
collect a claim for payment; or
(2) a third-party payor contracts to process or pay a
claim for payment by a preferred provider.
Sec. 324.107. APPLICABILITY OF OTHER LAW. If a provision of
this chapter and a provision of Chapter 1301, Insurance Code, apply
to the same person, conduct, or circumstance, Chapter 1301,
Insurance Code, controls.
SECTION 5. The changes in law made by this Act to Chapter
324, Health and Safety Code, apply only to services or supplies
provided by a health care facility to a consumer on or after the
effective date of this Act. Services or supplies provided before
the effective date of this Act are governed by the law in effect
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
SECTION 6. This Act takes effect September 1, 2009.