Texas 2009 - 81st Regular

Texas House Bill HB4289 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	81R4949 PB-F
2	2	By: Hunter H.B. No. 4289
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to required procedures regarding the ranking of physicians
8	8	by health benefit plan issuers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
11	11	by adding Chapter 1460 to read as follows:
12	12	CHAPTER 1460. PHYSICIAN RANKING BY HEALTH BENEFIT PLANS
13	13	SUBCHAPTER A. GENERAL PROVISIONS
14	14	Sec. 1460.001. DEFINITIONS. In this chapter:
15	15	(1) "Hearing panel" means the physician panel
16	16	described by Section 1460.056(a).
17	17	(2) "Physician" means an individual licensed to
18	18	practice medicine in this state under Subtitle B, Title 3,
19	19	Occupations Code.
20	20	Sec. 1460.002. APPLICABILITY. This chapter applies to any
21	21	health benefit plan that:
22	22	(1) provides benefits for medical or surgical expenses
23	23	incurred as a result of a health condition, accident, or sickness,
24	24	including an individual, group, blanket, or franchise insurance
25	25	policy or insurance agreement, a group hospital service contract,
26	26	or an individual or group evidence of coverage that is offered by:
27	27	(A) an insurance company;
28	28	(B) a group hospital service corporation
29	29	operating under Chapter 842;
30	30	(C) a fraternal benefit society operating under
31	31	Chapter 885;
32	32	(D) a stipulated premium company operating under
33	33	Chapter 884;
34	34	(E) a health maintenance organization operating
35	35	under Chapter 843;
36	36	(F) a multiple employer welfare arrangement that
37	37	holds a certificate of authority under Chapter 846;
38	38	(G) an approved nonprofit health corporation
39	39	that holds a certificate of authority under Chapter 844; or
40	40	(H) an entity not authorized under this code or
41	41	another insurance law of this state that contracts directly for
42	42	health care services on a risk-sharing basis, including a
43	43	capitation basis; or
44	44	(2) provides health and accident coverage through a
45	45	risk pool created under Chapter 172, Local Government Code,
46	46	notwithstanding Section 172.014, Local Government Code, or any
47	47	other law.
48	48	[Sections 1460.003-1460.050 reserved for expansion]
49	49	SUBCHAPTER B. RESTRICTIONS ON PHYSICIAN RANKING
50	50	Sec. 1460.051. PHYSICIAN RANKING. A health benefit plan
51	51	issuer, including a subsidiary or an affiliate of the health
52	52	benefit plan issuer, may not, in any manner, disseminate
53	53	information to the public that compares, rates, tiers, classifies,
54	54	measures, or ranks a physician's performance, efficiency, or
55	55	quality of practice against objective standards or the practice of
56	56	other physicians unless:
57	57	(1) the objective standards or comparison criteria
58	58	used by the health benefit plan issuer are disclosed to the
59	59	physician prior to the evaluation period;
60	60	(2) the data used to establish satisfaction of the
61	61	objective criteria or to make the comparison are available to the
62	62	physician for verification before any dissemination of information
63	63	to the public; and
64	64	(3) the health benefit plan issuer provides due
65	65	process to the physician as provided by this chapter.
66	66	Sec. 1460.052. INJUNCTIVE RELIEF. (a) A writ of injunction
67	67	may be granted by any district court if a health benefit plan issuer
68	68	disseminates, or intends to disseminate, information that
69	69	compares, rates, tiers, classifies, measures, or ranks physician
70	70	performance, efficiency, or quality without meeting the criteria
71	71	required under Section 1460.051.
72	72	(b) An action under Subsection (a) may be brought by any
73	73	affected physician or on the behalf of affected physicians.
74	74	(c) Subchapter B, Chapter 26, Civil Practice and Remedies
75	75	Code, does not apply to an action brought under this chapter.
76	76	Sec. 1460.053. DUE PROCESS; NOTICE OF INTENT. (a) Before a
77	77	health benefit plan issuer declines to invite a physician into a
78	78	preferred tier, classifies a physician into a particular tier, or
79	79	otherwise differentiates a physician from the physician's peers
80	80	based on performance, efficiency, or quality, the issuer must
81	81	notify the affected physician of its intent in a written notice
82	82	that meets the requirements of this section.
83	83	(b) A notice of intent issued under Subsection (a) must
84	84	include:
85	85	(1) a statement describing the proposed action of the
86	86	health benefit plan issuer and the reasons for that proposed
87	87	action;
88	88	(2) a statement that the affected physician has the
89	89	right to request a hearing on the proposed action as provided by
90	90	this chapter;
91	91	(3) any time limit within which the physician must
92	92	request a hearing under this chapter, which may not be less than 60
93	93	days from the date on which the notice of intent is issued; and
94	94	(4) a summary of the physician's rights under Section
95	95	1460.055.
96	96	Sec. 1460.054. NOTICE OF HEARING. If a hearing is requested
97	97	by a physician who receives a notice of intent under Section
98	98	1460.053, not later than the 30th day after the date on which the
99	99	physician requests the hearing the physician must be given a
100	100	written notice of the hearing that includes:
101	101	(1) a statement of the place, time, and date of the
102	102	hearing, which must be conducted:
103	103	(A) not less than 60 days after the date the
104	104	notice of the hearing is received by the physician; and
105	105	(B) not more than 90 days after the date the
106	106	notice of the hearing is received by the physician; and
107	107	(2) a list of the witnesses, if any, expected to
108	108	testify at the hearing on behalf of the health benefit plan issuer.
109	109	Sec. 1460.055. PHYSICIAN RIGHTS. A physician who requests
110	110	a hearing under this chapter has the following rights at the
111	111	hearing:
112	112	(1) the right to be represented by counsel;
113	113	(2) the right to have a record made of the proceedings
114	114	and to obtain a copy of the record for a reasonable charge;
115	115	(3) the right to call, examine, and cross-examine
116	116	witnesses;
117	117	(4) the right to present evidence;
118	118	(5) the right to submit a written statement to the
119	119	hearing panel at the close of the hearing; and
120	120	(6) the right to receive, following the hearing, the
121	121	written decision of the hearing panel, including a statement of the
122	122	basis for any recommendations by the panel.
123	123	Sec. 1460.056. HEARING PANEL; CONDUCT OF HEARING. (a) A
124	124	hearing requested under Section 1460.054 must be held before a
125	125	panel of three physicians who practice the same medical specialty
126	126	as the affected physician or a similar medical specialty.
127	127	(b) The order of presentation in the hearing shall be as
128	128	follows:
129	129	(1) opening statements by the health benefit plan
130	130	issuer followed by the physician or the physician's counsel;
131	131	(2) presentation of the case by the health benefit
132	132	plan issuer followed by presentation of the case by the physician or
133	133	the physician's counsel;
134	134	(3) rebuttal by the health benefit plan issuer
135	135	followed by the physician or the physician's counsel; and
136	136	(4) closing statements by the health benefit plan
137	137	issuer followed by the physician or the physician's counsel.
138	138	Sec. 1460.057. EFFECT OF NONAPPEARANCE; WAIVER. (a) The
139	139	hearing panel is not precluded from proceeding with a hearing
140	140	conducted under this chapter by the failure to appear at all or any
141	141	part of the hearing of:
142	142	(1) the affected physician or the physician's legal
143	143	counsel, if any; or
144	144	(2) any witness.
145	145	(b) Failure of a physician not represented by counsel or
146	146	failure of both a physician and the physician's counsel to appear
147	147	at the hearing is deemed a waiver of all procedural rights under
148	148	this chapter that could have been exercised by, or on behalf of, the
149	149	affected physician at the hearing.
150	150	Sec. 1460.058. EXAMINATION OF WITNESSES. Each of the
151	151	following persons present at a hearing conducted under this chapter
152	152	may examine or cross-examine any witness testifying at the hearing
153	153	in person, telephonically, or electronically through the Internet
154	154	or otherwise:
155	155	(1) the physician or, at the physician's option, the
156	156	physician's counsel, but not both;
157	157	(2) the representative of the health benefit plan
158	158	issuer, as designated by the issuer; and
159	159	(3) the members of the hearing panel.
160	160	Sec. 1460.059. BURDEN OF PROOF; DECISION. (a) The health
161	161	benefit plan issuer must prove, by a preponderance of evidence,
162	162	that:
163	163	(1) in the case of a methodology using objective
164	164	standards, the affected physician's performance, efficiency, or
165	165	quality and the effectiveness of the medical care delivered by the
166	166	physician has not met the standards disclosed under Section
167	167	1460.051; or
168	168	(2) in the case of a methodology using relative
169	169	comparison criteria, the data is accurate and correctly portrays
170	170	the affected physician's performance, efficiency, or quality
171	171	relative to other physicians in the same or similar medical
172	172	specialty with comparable patient populations.
173	173	(b) The decision of the hearing panel is binding.
174	174	(c) If the hearing panel's decision is that the health
175	175	benefit plan issuer has met its burden of proof, the health benefit
176	176	plan issuer may publish the comparison, rating, tier,
177	177	classification, measurement, or ranking.
178	178	(d) If the hearing panel's decision is that the health
179	179	benefit plan issuer has not met its burden of proof, the panel shall
180	180	instruct the health benefit plan issuer to appropriately modify the
181	181	comparison, rating, tier, classification, measurement, or ranking
182	182	before publication.
183	183	Sec. 1460.060. EFFECT OF CONTINUED DISAGREEMENT. (a) On
184	184	written notice that the affected physician disagrees with the
185	185	health benefit plan issuer's comparison, rating, tier,
186	186	classification, measurement, or ranking or the decision of the
187	187	hearing panel, the health benefit plan issuer shall prominently
188	188	display a symbol indicating the physician disputes the comparison,
189	189	rating, tier, classification, measurement, or ranking next to any
190	190	comparison, rating, tier, classification, measurement, or ranking
191	191	information for that physician.
192	192	(b) Each Internet web page displaying comparison, rating,
193	193	tier, classification, measurement, or ranking information must
194	194	contain a key explaining the meaning of the symbol required by
195	195	Subsection (a).
196	196	SECTION 2. This Act takes effect immediately if it receives
197	197	a vote of two-thirds of all the members elected to each house, as
198	198	provided by Section 39, Article III, Texas Constitution. If this
199	199	Act does not receive the vote necessary for immediate effect, this
200	200	Act takes effect September 1, 2009.