83R2664 KKR-D
By: Nelson S.B. No. 1059
A BILL TO BE ENTITLED
AN ACT
relating to the consideration of strategies by the Health and Human
Services Commission to ensure the appropriate use of diagnostic
ancillary services in the Medicaid program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.024162 to read as follows:
Sec. 531.024162. STRATEGIES TO ENSURE APPROPRIATE USE OF
DIAGNOSTIC ANCILLARY SERVICES. (a) The commission shall:
(1) adopt new cost-effective strategies to ensure the
appropriate use of diagnostic ancillary services in the Medicaid
program; and
(2) strengthen existing methods to reduce the use of
unnecessary diagnostic ancillary services in the Medicaid program.
(b) When considering the adoption of new cost-effective
strategies to ensure the appropriate use of diagnostic ancillary
services in the Medicaid program, the commission shall examine
implementing within the Medicaid fee-for-service model and the STAR
and STAR + PLUS Medicaid managed care programs a prior notification
program in which:
(1) outlier health care providers' use of diagnostic
ancillary services are compared to evidence-based clinical
guidelines; and
(2) health care providers are educated about the
appropriate use of diagnostic ancillary services.
(c) When considering strengthening existing methods to
reduce the use of unnecessary diagnostic ancillary services in the
Medicaid program, the commission shall examine:
(1) requiring every STAR and STAR + PLUS Medicaid
managed care program to implement a prior authorization program;
and
(2) modifying the existing prior authorization
programs within the Medicaid fee-for-service model and the STAR and
STAR + PLUS Medicaid managed care programs so that:
(A) the programs target health care providers who
order significantly more diagnostic ancillary services than other
providers who treat similar patients;
(B) outlier providers who order diagnostic
ancillary services inappropriately are required to participate in
the programs; and
(C) the programs are expanded to include
additional types of diagnostic ancillary services that account for
a significant share of spending, have evidence-based standards for
appropriate use, and exhibit variations in use among providers and
geographic areas.
(d) The commission shall examine options within the
Medicaid fee-for-service model and the STAR and STAR + PLUS
Medicaid managed care programs to improve payment accuracy for
diagnostic ancillary services and to reduce the financial incentive
for a health care provider to order unnecessary diagnostic
ancillary services to be performed at a facility in which the
provider has a financial interest. Options the commission shall
examine under this subsection and may consider implementing
include:
(1) accounting for duplications in the work of a
provider and the expenses relating to that work that occur when two
or more diagnostic ancillary services are provided at the same time
by:
(A) combining into a single payment rate or
comprehensive code multiple discrete diagnostic ancillary services
that are often provided at the same time by the same provider; or
(B) reducing the payment rate for subsequent
diagnostic ancillary services that are provided to a patient at the
same time by the same provider; and
(2) reducing the payment rates for certain diagnostic
ancillary services that are ordered and provided by the same
provider.
(e) The commission shall review strategies recommended by
the federal Medicare Payment Advisory Commission during fiscal year
2011 to reduce the use of unnecessary diagnostic ancillary services
in the Medicare program and consider adopting those strategies for
the Medicaid program.
(f) The commission shall identify cost-effective strategies
used by STAR and STAR + PLUS Medicaid managed care programs to
reduce the use of unnecessary diagnostic ancillary services and
consider:
(1) implementing those strategies within the Medicaid
fee-for-service model; and
(2) requiring the use of those strategies in other
STAR and STAR + PLUS Medicaid managed care programs.
SECTION 2. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2013.