Texas 2019 - 86th Regular

Texas House Bill HB3484 Compare Versions

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

Old	New	Differences
1	1	86R7770 SCL-F
2	2	By: Lucio III H.B. No. 3484
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to conduct of insurers providing preferred provider
8	8	benefit plans with respect to physician and health care provider
9	9	contracts and claims.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Sections 1301.066 and 1301.103, Insurance Code,
12	12	are amended to read as follows:
13	13	Sec. 1301.066. RETALIATION AGAINST PREFERRED PROVIDER
14	14	PROHIBITED. (a) An insurer may not engage in any retaliatory action
15	15	against a physician or health care provider[, including terminating
16	16	the physician's or provider's participation in the preferred
17	17	provider benefit plan or refusing to renew the physician's or
18	18	provider's contract,] because the physician or provider has:
19	19	(1) on behalf of an insured, reasonably filed a
20	20	complaint against the insurer; or
21	21	(2) appealed a decision of the insurer.
22	22	(b) A retaliatory action under Subsection (a) includes:
23	23	(1) terminating the physician's or provider's
24	24	participation in the preferred provider benefit plan;
25	25	(2) refusing to renew the physician's or provider's
26	26	contract;
27	27	(3) implementing measurable penalties in the contract
28	28	negotiation process; and
29	29	(4) engaging in an unfair or deceptive contract
30	30	negotiation practice.
31	31	Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. (a)
32	32	Except as provided by Sections 1301.104 and 1301.1054, not later
33	33	than the 45th day after the date an insurer receives a clean claim
34	34	from a preferred provider in a nonelectronic format or the 30th day
35	35	after the date an insurer receives a clean claim from a preferred
36	36	provider that is electronically submitted, the insurer shall make a
37	37	determination of whether the claim is payable and:
38	38	(1) if the insurer determines the entire claim is
39	39	payable, pay the total amount of the claim in accordance with the
40	40	contract between the preferred provider and the insurer;
41	41	(2) if the insurer determines a portion of the claim is
42	42	payable, pay the portion of the claim that is not in dispute and
43	43	notify the preferred provider in writing why the remaining portion
44	44	of the claim will not be paid; or
45	45	(3) if the insurer determines that the claim is not
46	46	payable, notify the preferred provider in writing why the claim
47	47	will not be paid.
48	48	(b) An insurer shall provide notice under Subsection (a)
49	49	electronically if the preferred provider's clean claim was
50	50	electronically submitted.
51	51	SECTION 2. Section 1301.105, Insurance Code, is amended by
52	52	amending Subsection (d) and adding Subsection (e) to read as
53	53	follows:
54	54	(d) If the preferred provider does not supply information
55	55	reasonably requested by the insurer in connection with the audit,
56	56	the insurer shall [may]:
57	57	(1) notify the provider in writing that the provider
58	58	must provide the information not later than the 45th day after the
59	59	date of the notice or forfeit the amount of the claim; and
60	60	(2) if the provider does not provide the information
61	61	required by this section, recover the amount of the claim.
62	62	(e) An insurer shall make a request or provide information
63	63	under this section electronically if the preferred provider's clean
64	64	claim was electronically submitted.
65	65	SECTION 3. Sections 1301.1051 and 1301.1052, Insurance
66	66	Code, are amended to read as follows:
67	67	Sec. 1301.1051. COMPLETION OF AUDIT. (a) The insurer must
68	68	complete an audit under Section 1301.105 on or before the 180th day
69	69	after the date the clean claim is received by the insurer, and any
70	70	additional payment due a preferred provider or any refund due the
71	71	insurer shall be made not later than the 30th day after the
72	72	completion of the audit.
73	73	(b) An insurer may not recover a payment on an audited claim
74	74	until a final audit is completed.
75	75	(c) An insurer shall provide written notice to the preferred
76	76	provider of the insurer's failure to complete an audit in the time
77	77	required by Subsection (a) not later than the 15th day after the
78	78	date on which the insurer is required to complete the audit under
79	79	that subsection.
80	80	Sec. 1301.1052. PREFERRED PROVIDER APPEAL AFTER AUDIT. (a)
81	81	If a preferred provider disagrees with a refund request made by an
82	82	insurer based on an audit under Section 1301.105, the insurer shall
83	83	provide the provider with an opportunity to appeal in accordance
84	84	with this section, and the insurer may not attempt to recover the
85	85	payment until all appeal rights are exhausted.
86	86	(b) An insurer shall provide a reasonable mechanism for an
87	87	appeal requested under Subsection (a). The review mechanism must
88	88	incorporate, in an advisory role only, a review panel.
89	89	(c) A review panel described by Subsection (b) must be
90	90	composed of at least three preferred provider representatives
91	91	selected by the insurer from a list of preferred providers. The
92	92	preferred providers contracting with the insurer in the applicable
93	93	service area shall provide the list of preferred provider
94	94	representatives to the insurer.
95	95	(d) On request, the insurer shall provide to the affected
96	96	preferred provider:
97	97	(1) the panel's composition and recommendation; and
98	98	(2) a written explanation of the insurer's
99	99	determination, if that determination is contrary to the panel's
100	100	recommendation.
101	101	SECTION 4. Subchapter C, Chapter 1301, Insurance Code, is
102	102	amended by adding Section 1301.10525 to read as follows:
103	103	Sec. 1301.10525. DEPARTMENT REVIEW OF AUDITS. (a) The
104	104	commissioner by rule shall establish procedures for a preferred
105	105	provider to submit a request for the department to review an audit
106	106	conducted by an insurer under this subchapter. The department
107	107	review of an audit is a contested case under Chapter 2001,
108	108	Government Code.
109	109	(b) If the department determines that an audit for which a
110	110	preferred provider requested review resulted in unreasonable costs
111	111	for the preferred provider, unnecessarily delayed or prevented
112	112	payment of a claim, or otherwise violated this subchapter or rules
113	113	adopted under this subchapter, the department shall:
114	114	(1) award compensatory damages to the preferred
115	115	provider incurred as a result of the audit; and
116	116	(2) order the insurer to pay to the department the
117	117	costs incurred by the department in reviewing the audit.
118	118	SECTION 5. Section 1301.132, Insurance Code, is amended by
119	119	adding Subsections (c), (d), and (e) to read as follows:
120	120	(c) An insurer shall provide a reasonable mechanism for an
121	121	appeal requested under Subsection (b). The review mechanism must
122	122	incorporate, in an advisory role only, a review panel.
123	123	(d) A review panel described by Subsection (c) must be
124	124	composed of at least three preferred provider representatives
125	125	selected by the insurer from a list of preferred providers. The
126	126	preferred providers contracting with the insurer in the applicable
127	127	service area shall provide the list of preferred provider
128	128	representatives to the insurer.
129	129	(e) On request, the insurer shall provide to the affected
130	130	preferred provider:
131	131	(1) the panel's composition and recommendation; and
132	132	(2) a written explanation of the insurer's
133	133	determination, if that determination is contrary to the panel's
134	134	recommendation.
135	135	SECTION 6. (a) The changes in law made by this Act apply to
136	136	a claim for payment made on or after the effective date of this Act
137	137	unless the claim is made under a contract that was entered into
138	138	before the effective date of this Act and that, at the time the
139	139	claim is made, has not been renewed or was last renewed before the
140	140	effective date of this Act.
141	141	(b) A claim made before the effective date of this Act or
142	142	made on or after the effective date of this Act under a contract
143	143	described by Subsection (a) of this section is governed by the law
144	144	as it existed immediately before the effective date of this Act, and
145	145	that law is continued in effect for that purpose.
146	146	SECTION 7. This Act takes effect September 1, 2019.