Texas 2019 - 86th Regular

Texas House Bill HB2151 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	By: Muñoz, Jr., Martinez, Guillen, Guerra H.B. No. 2151
	1	+	86R11289 MEW-D
	2	+	By: Muñoz, Jr. H.B. No. 2151
2	3
3	4
4	5		A BILL TO BE ENTITLED
5	6		AN ACT
6	7		relating to the use of extrapolation by a health maintenance
7	8		organization or an insurer to audit claims.
8	9		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	10		SECTION 1. Section 843.010, Insurance Code, is amended to
10	11		read as follows:
11	12		Sec. 843.010. APPLICABILITY OF CERTAIN PROVISIONS TO
12	13		GOVERNMENTAL HEALTH BENEFIT PLANS. Sections 843.306(f), 843.322,
13	14		and 843.363(a)(4) do not apply to coverage under:
14	15		(1) the child health plan program under Chapter 62,
15	16		Health and Safety Code, or the health benefits plan for children
16	17		under Chapter 63, Health and Safety Code; or
17	18		(2) a Medicaid program, including a Medicaid managed
18	19		care program operated under Chapter 533, Government Code.
19	20		SECTION 2. Subchapter I, Chapter 843, Insurance Code, is
20	21		amended by adding Section 843.322 to read as follows:
21	22		Sec. 843.322. USE OF EXTRAPOLATION PROHIBITED. (a) In this
22	23		section, "extrapolation" means a mathematical process or technique
23	24		used by a health maintenance organization in the audit of a
24	25		participating physician or provider to estimate audit results or
25	26		findings for a larger batch or group of claims not reviewed by the
26	27		health maintenance organization.
27	28		(b) A health maintenance organization may not use
28	29		extrapolation to complete an audit of a participating physician or
29	30		provider. Any additional payment due a participating physician or
30	31		provider or any refund due the health maintenance organization must
31	32		be based on the actual overpayment or underpayment and may not be
32	33		based on an extrapolation.
33	34		SECTION 3. Subchapter B, Chapter 1301, Insurance Code, is
34	35		amended by adding Section 1301.0642 to read as follows:
35	36		Sec. 1301.0642. USE OF EXTRAPOLATION PROHIBITED. (a) In
36	37		this section, "extrapolation" means a mathematical process or
37		-	technique used by an insurer in the audit of a preferred or
38		-	~~nonpreferred provider to~~ estimate audit results or findings for a
39		-	~~larger batch or group of~~ claims not reviewed by the insurer.
	38	+	technique used by an insurer in the audit of a preferred provider to
	39	+	estimate audit results or findings for a larger batch or group of
	40	+	claims not reviewed by the insurer.
40	41		(b) An insurer may not use extrapolation to complete an
41		-	audit of a preferred or nonpreferred provider. Any additional
42		-	payment due a preferred or nonpreferred provider or any refund due
43		-	the insurer must be based on the actual overpayment or underpayment
44		-	and may not be based on an extrapolation.
45		-	(c) If a payment for which a patient has signed an agreement
46		-	to pay is due a preferred or nonpreferred provider, the patient is
47		-	considered to have assumed full financial responsibility for the
48		-	payment, and the payment may not be used as a basis for a claim of
49		-	nonpayment against the insurer.
	42	+	audit of a preferred provider. Any additional payment due a
	43	+	preferred provider or any refund due the insurer must be based on
	44	+	the actual overpayment or underpayment and may not be based on an
	45	+	extrapolation.
50	46		SECTION 4. The change in law made by this Act applies only
51	47		to the audit of a physician or provider under a contract with an
52	48		insurer or health maintenance organization entered into or renewed
53	49		on or after the effective date of this Act.
54	50		SECTION 5. This Act takes effect September 1, 2019.