82R10272 AJA-D
By: Smithee H.B. No. 3087
A BILL TO BE ENTITLED
AN ACT
relating to payment for services provided by certain physicians and
health care providers to individuals covered by managed care plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 1467, Insurance Code, is
amended by adding Section 1467.0021 to read as follows:
Sec. 1467.0021. CERTAIN CLAIMS EXCLUDED. This chapter does
not apply to a claim with respect to services to which Chapter 1468
applies.
SECTION 2. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1468 to read as follows:
CHAPTER 1468. PAYMENT OF CERTAIN SERVICES PROVIDED TO INDIVIDUAL
COVERED BY MANAGED CARE PLAN
Sec. 1468.001. DEFINITIONS. In this chapter:
(1) "Facility-based physician" means a radiologist,
an anesthesiologist, a pathologist, an emergency department
physician, or a neonatologist:
(A) to whom the facility has granted clinical
privileges; and
(B) who provides services to patients of the
facility under those clinical privileges.
(2) "Managed care plan" means a plan under which a
health maintenance organization, preferred provider benefit plan
issuer, or other organization provides or arranges for health care
benefits to plan enrollees and requires or encourages plan
enrollees to use health care practitioners and health care
facilities designated by the plan.
Sec. 1468.002. APPLICABILITY OF CHAPTER. This chapter
applies to:
(1) emergency medical services provided by an
out-of-network provider; and
(2) medical or health care services provided:
(A) to an individual covered by a managed care
plan;
(B) within a hospital or similar facility; and
(C) by a facility-based physician or provider who
is an out-of-network provider.
Sec. 1468.003. PAYMENT FROM MANAGED CARE PLAN: USUAL AND
CUSTOMARY CHARGE. A physician or health care provider who provides
a medical or health care service described by Section 1468.002 to an
individual covered for the service under a managed care plan is
entitled to payment from the individual's managed care plan in an
amount equal to the usual and customary charge for the service,
minus any deductible, copayment, or coinsurance for which the
individual is responsible under the plan.
Sec. 1468.004. ARBITRATION OF USUAL AND CUSTOMARY CHARGE.
If a physician or health care provider and a managed care plan
issuer do not agree on the usual and customary charge for a medical
or health care service that is subject to this chapter, the
physician or health care provider or the managed care plan issuer
may submit the dispute to arbitration to determine the usual and
customary charge.
Sec. 1468.005. ARBITRATION PROCEDURES; ARBITRATOR
QUALIFICATIONS. (a) The commissioner by rule shall:
(1) establish procedures for conducting an
arbitration under this chapter; and
(2) prescribe qualifications for serving as an
arbitrator under this chapter.
(b) The department shall maintain a list of arbitrators
qualified to conduct arbitrations under this chapter.
Sec. 1468.006. APPEAL OF ARBITRATOR DETERMINATION. (a) On
or before the 60th day after the date an arbitrator determines a
usual and customary charge under this chapter, either party to the
arbitration may file a petition for judicial review of the
determination in a district court.
(b) The standard of review for judicial review under this
section is de novo.
(c) In an action under this section, the amount determined
by the arbitrator to be the usual and customary charge shall be
admitted into evidence. There is a rebuttable presumption that the
amount determined by the arbitrator is the usual and customary
charge.
(d) The party that prevails in an action under this section
is entitled to an award of the party's reasonable attorney's fees
incurred in connection with the action.
(e) The managed care plan shall promptly pay the physician
or provider the amount of the usual and customary charge determined
by the court under this section.
Sec. 1468.007. APPLICABILITY OF CERTAIN OTHER LAW. Except
to the extent of any conflict with this section, Chapter 171, Civil
Practice and Remedies Code, applies to an arbitration conducted
under this chapter.
Sec. 1468.008. PAYMENT FROM COVERED INDIVIDUAL. (a) Unless
an individual who receives a medical or health care service to which
this chapter applies agrees before the service is provided to a
total charge for the service that exceeds the usual and customary
charge, the physician or provider is not entitled to payment from
the individual in excess of any required deductible, copayment, or
coinsurance.
(b) If the physician or provider seeks to recover from the
individual an amount that exceeds the amount allowed under this
section, the physician or provider must:
(1) notify the individual of the usual and customary
rate established in accordance with this chapter; and
(2) notify the individual that the individual is not
required by law to pay the portion of the fee that exceeds the usual
and customary rate unless the individual agreed to a higher rate
before the service was provided.
(c) If a physician or provider bills an individual in
violation of this section and the individual pays an amount that is
higher than the individual would be required to pay under this
section, the individual may file an action against the physician or
provider to recover the amount of the overpayment and the
individual's reasonable attorney's fees incurred in connection with
recovering the overpayment.
(d) If a physician or health care provider files an action
against an individual to recover payment for services that are
subject to this chapter and is found to be seeking payment that
exceeds the amount for which the individual is liable under this
section, the individual is entitled to recover the individual's
reasonable attorney's fees incurred in connection with the action.
SECTION 3. The change in law made by this Act applies only
to medical or health care services provided on or after the
effective date of this Act to an individual covered under a managed
care plan delivered, issued for delivery, or renewed on or after the
effective date of this Act and payment for those services.
SECTION 4. This Act takes effect January 1, 2012.