Texas 2015 - 84th Regular

Texas House Bill HB1638 Compare Versions

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

Old	New	Differences
1	1	84R7389 SCL-F
2	2	By: Smithee H.B. No. 1638
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to nonpreferred provider claims under a preferred provider
8	8	benefit plan related to emergency care.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1301, Insurance Code, is amended by
11	11	adding Subchapter F to read as follows:
12	12	SUBCHAPTER F. NONPREFERRED PROVIDER CLAIMS RELATED TO EMERGENCY
13	13	CARE PROVIDED TO INSUREDS; ARBITRATION
14	14	Sec. 1301.251. DEFINITIONS. In this subchapter:
15	15	(1) "Chief administrative law judge" means the chief
16	16	administrative law judge of the State Office of Administrative
17	17	Hearings.
18	18	(2) "Emergency care" has the meaning assigned by
19	19	Section 1301.155.
20	20	Sec. 1301.252. APPLICABILITY OF SUBCHAPTER. (a) This
21	21	subchapter does not apply to health care services, including
22	22	emergency care, in which physician fees are subject to schedules or
23	23	other monetary limitations under any other law, including workers'
24	24	compensation under Title 5, Labor Code.
25	25	(b) This subchapter applies only to emergency care
26	26	provided:
27	27	(1) to an insured;
28	28	(2) within a hospital, freestanding emergency medical
29	29	care facility, or similar facility that is a preferred provider;
30	30	and
31	31	(3) by a facility-based physician or health care
32	32	provider who is a nonpreferred provider.
33	33	(c) This subchapter does not apply to:
34	34	(1) the Employees Retirement System of Texas or
35	35	another entity issuing or administering a basic coverage plan under
36	36	Chapter 1551;
37	37	(2) the Teacher Retirement System of Texas or another
38	38	entity issuing or administering a basic plan under Chapter 1575 or a
39	39	health coverage plan under Chapter 1579; or
40	40	(3) The Texas A&M University System or The University
41	41	of Texas System or another entity issuing or administering basic
42	42	coverage under Chapter 1601.
43	43	Sec. 1301.253. PAYMENT OF NONPREFERRED PROVIDER BILL.
44	44	Notwithstanding Section 1301.005 or any other law, an insurer shall
45	45	pay a nonpreferred provider a reasonable amount for emergency care
46	46	provided by the nonpreferred provider to an insured.
47	47	Sec. 1301.254. HOLD HARMLESS FOR INSUREDS. A nonpreferred
48	48	provider may not bill an insured eligible to receive services under
49	49	a preferred provider benefit plan, and the insured is not liable to
50	50	the provider, for emergency care provided in a hospital,
51	51	freestanding emergency medical care facility, or similar facility
52	52	that is a preferred provider except for any applicable copayment,
53	53	coinsurance, or deductible that would be owed if the provider was a
54	54	preferred provider under the plan.
55	55	Sec. 1301.255. ARBITRATOR QUALIFICATIONS. (a) Except as
56	56	provided by Subsection (b), to qualify for an appointment as an
57	57	arbitrator under this subchapter, a person must have completed at
58	58	least 40 classroom hours of training in dispute resolution
59	59	techniques in a course conducted by an alternative dispute
60	60	resolution organization or other dispute resolution organization
61	61	approved by the chief administrative law judge.
62	62	(b) A person not qualified under Subsection (a) may be
63	63	appointed as an arbitrator on agreement of the parties.
64	64	(c) A person may not act as an arbitrator for a claim
65	65	settlement dispute if the person has been employed by, consulted
66	66	for, or otherwise had a business relationship with an insurer
67	67	offering the preferred provider benefit plan or a health care
68	68	provider during the three years immediately preceding the request
69	69	for arbitration.
70	70	Sec. 1301.256. APPOINTMENT OF ARBITRATOR. (a) An
71	71	arbitration under this subchapter shall be conducted by one
72	72	arbitrator.
73	73	(b) The chief administrative law judge shall appoint the
74	74	arbitrator through a random assignment from a list of qualified
75	75	arbitrators maintained by the State Office of Administrative
76	76	Hearings.
77	77	(c) Notwithstanding Subsection (b), a person other than an
78	78	arbitrator appointed by the chief administrative law judge may
79	79	conduct the arbitration on agreement of all of the parties and
80	80	notice to the chief administrative law judge.
81	81	Sec. 1301.257. REQUEST AND PRELIMINARY PROCEDURES FOR
82	82	ARBITRATION. (a) If a dispute arises over the nonpreferred
83	83	provider's fee or the insurer's payment to the provider, the
84	84	provider or insurer may request arbitration under this subchapter.
85	85	(b) A request for arbitration must be provided to the
86	86	department on a form prescribed by the commissioner and must
87	87	include:
88	88	(1) the name of the nonpreferred provider and insurer;
89	89	(2) a brief description of the claim to be resolved,
90	90	including the nonpreferred provider's fee and the insurer's payment
91	91	to the provider;
92	92	(3) contact information, including a telephone
93	93	number, for the requesting party and the party's counsel, if the
94	94	party retains counsel; and
95	95	(4) any other information the commissioner may require
96	96	by rule.
97	97	(c) On receipt of a request for arbitration, the department
98	98	shall notify the nonpreferred provider, insurer, and insured of the
99	99	request. In the notice to the insured, the department must explain
100	100	in plain language the amount billed by the provider, the amount paid
101	101	by the insurer, that either the provider or insurer has requested
102	102	arbitration, and that the insured has a right to participate in the
103	103	informal settlement teleconference or arbitration.
104	104	(d) In an effort to settle the claim before arbitration, the
105	105	nonpreferred provider and insurer shall participate in an informal
106	106	settlement teleconference not later than the 30th day after the
107	107	date on which a party submits a request for arbitration under this
108	108	section. The insured may elect to participate in the
109	109	teleconference.
110	110	(e) A claim to be resolved under this subchapter that does
111	111	not settle as a result of a teleconference conducted under
112	112	Subsection (d) must be referred to the State Office of
113	113	Administrative Hearings by the department, and an arbitration
114	114	hearing must be conducted in the county in which the medical
115	115	services were rendered.
116	116	(f) The State Office of Administrative Hearings may
117	117	implement measures, including an additional informal settlement
118	118	teleconference, to encourage early and informal resolution to a
119	119	billing dispute before arbitration commences.
120	120	(g) The insured may elect to participate in the arbitration.
121	121	Sec. 1301.258. CONDUCT OF ARBITRATION. (a) In arbitration
122	122	conducted under this subchapter, an arbitrator shall determine
123	123	whether the nonpreferred provider's billed charge or the insurer's
124	124	payment to the provider is the reasonable amount to be paid for the
125	125	emergency care that is the basis for the claim. In determining the
126	126	amount to be paid, the arbitrator shall consider the criteria under
127	127	Section 1301.259.
128	128	(b) An arbitrator shall determine the amount to be paid not
129	129	later than the 30th day after the date the arbitrator receives the
130	130	claim.
131	131	(c) If an arbitrator determines, based on the nonpreferred
132	132	provider's billed charge and insurer's payment, that a settlement
133	133	between the provider and insurer is reasonably likely or that both
134	134	the provider's billed charge and insurer's payment represent
135	135	unreasonable extremes, then the arbitrator may require the parties
136	136	to negotiate in good faith for a settlement. The arbitrator may
137	137	grant the parties not more than 10 business days for the
138	138	negotiation, which run concurrently with the 30-day period for
139	139	arbitration.
140	140	(d) Except as provided by this subchapter, the arbitrator
141	141	must hold in strict confidence all information provided to the
142	142	arbitrator by a party and all communications of the arbitrator with
143	143	a party.
144	144	(e) A party must have an opportunity during the arbitration
145	145	to speak and state the party's position.
146	146	(f) The arbitrator may:
147	147	(1) receive in evidence any documentary evidence or
148	148	other information the arbitrator considers relevant;
149	149	(2) administer oaths; and
150	150	(3) issue subpoenas to require:
151	151	(A) the attendance and testimony of witnesses;
152	152	and
153	153	(B) the production of books, records, and other
154	154	evidence relevant to a claim presented for arbitration.
155	155	(g) The determination of an arbitrator is binding on the
156	156	nonpreferred provider and insurer and is admissible in court or in
157	157	an administrative proceeding.
158	158	Sec. 1301.259. CRITERIA FOR DETERMINING PAYMENT AMOUNT. In
159	159	determining the appropriate amount to be paid for the emergency
160	160	care, the arbitrator shall consider all relevant factors,
161	161	including:
162	162	(1) whether there is a gross disparity between the
163	163	billed charge for the same services rendered by the nonpreferred
164	164	provider as compared to:
165	165	(A) payments to the provider for the same
166	166	services rendered by the provider to other patients in preferred
167	167	provider benefit plans in which the provider is a nonpreferred
168	168	provider; and
169	169	(B) payments by the insurer to reimburse
170	170	similarly qualified nonpreferred providers for the same services in
171	171	the same region;
172	172	(2) the level of training, education, and experience
173	173	of the nonpreferred provider;
174	174	(3) the nonpreferred provider's usual charge for
175	175	comparable services with regard to insureds in preferred provider
176	176	benefit plans in which the provider is a nonpreferred provider;
177	177	(4) the circumstances and complexity of the particular
178	178	case, including time and place of the services;
179	179	(5) individual patient characteristics; and
180	180	(6) the usual and customary cost of the service.
181	181	Sec. 1301.260. PAYMENT FOR ARBITRATION COSTS. (a) If an
182	182	arbitrator determines the insurer's payment as the amount to be
183	183	paid, the nonpreferred provider shall pay the arbitration costs.
184	184	(b) If an arbitrator determines the nonpreferred provider's
185	185	billed charge as the amount to be paid, the insurer shall pay the
186	186	arbitration costs.
187	187	(c) If good faith negotiation under Section 1301.258(c)
188	188	results in a settlement between the nonpreferred provider and
189	189	insurer, the provider and insurer shall evenly divide and share the
190	190	costs of arbitration.
191	191	SECTION 2. Subchapter A, Chapter 1467, Insurance Code, is
192	192	amended by adding Section 1467.0021 to read as follows:
193	193	Sec. 1467.0021. CERTAIN CLAIMS EXCLUDED. This chapter does
194	194	not apply to a claim with respect to which Subchapter F, Chapter
195	195	1301, applies.
196	196	SECTION 3. The change in law made by this Act applies only
197	197	to a payment for emergency care provided by a nonpreferred provider
198	198	at a health care facility that is a preferred provider on or after
199	199	January 1, 2016. Payment for emergency care provided before
200	200	January 1, 2016, is governed by the law in effect immediately before
201	201	the effective date of this Act, and that law is continued in effect
202	202	for that purpose.
203	203	SECTION 4. This Act takes effect September 1, 2015.