Relating to payment of claims to pharmacies and pharmacists.
Impact
The legislation is designed to streamline processes for pharmacies and pharmacists, ensuring that they receive timely payments for services rendered. By defining strict timeframes for HMOs and PBMs, the bill aims to enhance operational efficiency and reduce delays in compensation, which can significantly impact small and independent pharmacies. Additionally, the prohibition against using extrapolation audits in evaluating pharmacy claims seeks to protect pharmacists from potentially unjust penalties based on unverified estimations of their performance.
Summary
House Bill 2292 addresses the payment of claims to pharmacies and pharmacists by amending the Texas Insurance Code. The bill specifically outlines the timelines for health maintenance organizations (HMOs) and pharmacy benefit managers (PBMs) to respond to clean claims made by providers. For claims submitted electronically, HMOs are mandated to determine their payability within 30 days and pay the full amount by the 18th day after the claim is adjudicated. Non-electronic submissions have a slightly longer deadline of 45 days to receive a decision and up to 21 days to receive payment.
Contention
Notable points of contention surrounding HB 2292 include the balance of power between HMOs, PBMs, and pharmacies. Critics argue that the changes may lead to unintended consequences for HMOs, potentially complicating their administrative procedures and financial viability. On the other hand, proponents assert that the bill is essential for fostering a more equitable environment for pharmacies, particularly as many face challenges with delayed payments and stringent auditing processes. The ongoing dialogue in legislative sessions highlighted differing views on how to ensure both accountability and fair treatment within the healthcare system.