85R3340 MEW-D
By: Muñoz, Jr. H.B. No. 1649
A BILL TO BE ENTITLED
AN ACT
relating to the use of extrapolation by a health maintenance
organization or an insurer to audit claims.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.340, Insurance Code, is amended by
adding Subsections (f) and (g) to read as follows:
(f) A health maintenance organization may not use
extrapolation to complete an audit of a participating physician or
provider. Any additional payment due a participating physician or
provider or any refund due the health maintenance organization must
be based on the actual overpayment or underpayment and may not be
based on an extrapolation.
(g) In this section, "extrapolation" means a mathematical
process or technique used by a health maintenance organization in
the audit of a participating physician or provider to estimate
audit results or findings for a larger batch or group of claims not
reviewed by the health maintenance organization.
SECTION 2. Section 1301.105, Insurance Code, is amended by
adding Subsections (e) and (f) to read as follows:
(e) An insurer may not use extrapolation to complete an
audit of a preferred provider. Any additional payment due a
preferred provider or any refund due the insurer must be based on
the actual overpayment or underpayment and may not be based on an
extrapolation.
(f) In this section, "extrapolation" means a mathematical
process or technique used by an insurer in the audit of a preferred
provider to estimate audit results or findings for a larger batch or
group of claims not reviewed by the insurer.
SECTION 3. The change in law made by this Act applies only
to the audit of a physician or provider under a contract with an
insurer or health maintenance organization entered into or renewed
on or after the effective date of this Act.
SECTION 4. This Act takes effect September 1, 2017.