86R7770 SCL-F
By: Lucio III H.B. No. 3484
A BILL TO BE ENTITLED
AN ACT
relating to conduct of insurers providing preferred provider
benefit plans with respect to physician and health care provider
contracts and claims.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Sections 1301.066 and 1301.103, Insurance Code,
are amended to read as follows:
Sec. 1301.066. RETALIATION AGAINST PREFERRED PROVIDER
PROHIBITED. (a) An insurer may not engage in any retaliatory action
against a physician or health care provider[, including terminating
the physician's or provider's participation in the preferred
provider benefit plan or refusing to renew the physician's or
provider's contract,] because the physician or provider has:
(1) on behalf of an insured, reasonably filed a
complaint against the insurer; or
(2) appealed a decision of the insurer.
(b) A retaliatory action under Subsection (a) includes:
(1) terminating the physician's or provider's
participation in the preferred provider benefit plan;
(2) refusing to renew the physician's or provider's
contract;
(3) implementing measurable penalties in the contract
negotiation process; and
(4) engaging in an unfair or deceptive contract
negotiation practice.
Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. (a)
Except as provided by Sections 1301.104 and 1301.1054, not later
than the 45th day after the date an insurer receives a clean claim
from a preferred provider in a nonelectronic format or the 30th day
after the date an insurer receives a clean claim from a preferred
provider that is electronically submitted, the insurer shall make a
determination of whether the claim is payable and:
(1) if the insurer determines the entire claim is
payable, pay the total amount of the claim in accordance with the
contract between the preferred provider and the insurer;
(2) if the insurer determines a portion of the claim is
payable, pay the portion of the claim that is not in dispute and
notify the preferred provider in writing why the remaining portion
of the claim will not be paid; or
(3) if the insurer determines that the claim is not
payable, notify the preferred provider in writing why the claim
will not be paid.
(b) An insurer shall provide notice under Subsection (a)
electronically if the preferred provider's clean claim was
electronically submitted.
SECTION 2. Section 1301.105, Insurance Code, is amended by
amending Subsection (d) and adding Subsection (e) to read as
follows:
(d) If the preferred provider does not supply information
reasonably requested by the insurer in connection with the audit,
the insurer shall [may]:
(1) notify the provider in writing that the provider
must provide the information not later than the 45th day after the
date of the notice or forfeit the amount of the claim; and
(2) if the provider does not provide the information
required by this section, recover the amount of the claim.
(e) An insurer shall make a request or provide information
under this section electronically if the preferred provider's clean
claim was electronically submitted.
SECTION 3. Sections 1301.1051 and 1301.1052, Insurance
Code, are amended to read as follows:
Sec. 1301.1051. COMPLETION OF AUDIT. (a) The insurer must
complete an audit under Section 1301.105 on or before the 180th day
after the date the clean claim is received by the insurer, and any
additional payment due a preferred provider or any refund due the
insurer shall be made not later than the 30th day after the
completion of the audit.
(b) An insurer may not recover a payment on an audited claim
until a final audit is completed.
(c) An insurer shall provide written notice to the preferred
provider of the insurer's failure to complete an audit in the time
required by Subsection (a) not later than the 15th day after the
date on which the insurer is required to complete the audit under
that subsection.
Sec. 1301.1052. PREFERRED PROVIDER APPEAL AFTER AUDIT. (a)
If a preferred provider disagrees with a refund request made by an
insurer based on an audit under Section 1301.105, the insurer shall
provide the provider with an opportunity to appeal in accordance
with this section, and the insurer may not attempt to recover the
payment until all appeal rights are exhausted.
(b) An insurer shall provide a reasonable mechanism for an
appeal requested under Subsection (a). The review mechanism must
incorporate, in an advisory role only, a review panel.
(c) A review panel described by Subsection (b) must be
composed of at least three preferred provider representatives
selected by the insurer from a list of preferred providers. The
preferred providers contracting with the insurer in the applicable
service area shall provide the list of preferred provider
representatives to the insurer.
(d) On request, the insurer shall provide to the affected
preferred provider:
(1) the panel's composition and recommendation; and
(2) a written explanation of the insurer's
determination, if that determination is contrary to the panel's
recommendation.
SECTION 4. Subchapter C, Chapter 1301, Insurance Code, is
amended by adding Section 1301.10525 to read as follows:
Sec. 1301.10525. DEPARTMENT REVIEW OF AUDITS. (a) The
commissioner by rule shall establish procedures for a preferred
provider to submit a request for the department to review an audit
conducted by an insurer under this subchapter. The department
review of an audit is a contested case under Chapter 2001,
Government Code.
(b) If the department determines that an audit for which a
preferred provider requested review resulted in unreasonable costs
for the preferred provider, unnecessarily delayed or prevented
payment of a claim, or otherwise violated this subchapter or rules
adopted under this subchapter, the department shall:
(1) award compensatory damages to the preferred
provider incurred as a result of the audit; and
(2) order the insurer to pay to the department the
costs incurred by the department in reviewing the audit.
SECTION 5. Section 1301.132, Insurance Code, is amended by
adding Subsections (c), (d), and (e) to read as follows:
(c) An insurer shall provide a reasonable mechanism for an
appeal requested under Subsection (b). The review mechanism must
incorporate, in an advisory role only, a review panel.
(d) A review panel described by Subsection (c) must be
composed of at least three preferred provider representatives
selected by the insurer from a list of preferred providers. The
preferred providers contracting with the insurer in the applicable
service area shall provide the list of preferred provider
representatives to the insurer.
(e) On request, the insurer shall provide to the affected
preferred provider:
(1) the panel's composition and recommendation; and
(2) a written explanation of the insurer's
determination, if that determination is contrary to the panel's
recommendation.
SECTION 6. (a) The changes in law made by this Act apply to
a claim for payment made on or after the effective date of this Act
unless the claim is made under a contract that was entered into
before the effective date of this Act and that, at the time the
claim is made, has not been renewed or was last renewed before the
effective date of this Act.
(b) A claim made before the effective date of this Act or
made on or after the effective date of this Act under a contract
described by Subsection (a) of this section is governed by the law
as it existed immediately before the effective date of this Act, and
that law is continued in effect for that purpose.
SECTION 7. This Act takes effect September 1, 2019.