By: Deshotel, Raymond, Zedler H.B. No. 3721
A BILL TO BE ENTITLED
AN ACT
relating to an independent review organization to conduct reviews
of certain medical necessity determinations under the Medicaid
managed care program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.039 to read as follows:
Sec. 533.039. INDEPENDENT REVIEW ORGANIZATIONS. (a) In
this section, "independent review organization" means an
organization certified under Chapter 4202, Insurance Code.
(b) The commission shall contract with an independent
review organization to make review determinations with respect to
disputes at issue in requests for appeal submitted to the
commission challenging a medical necessity determination of a
managed care organization that contracts with the commission under
this chapter, except as provided by Subsection (b-1) or (g). The
executive commissioner by rule shall determine:
(1) the manner in which an independent review
organization is to settle the disputes;
(2) when, subject to Subsection (b-1), in the appeals
process, an organization may be accessed; and
(3) the recourse available after the organization
makes a review determination.
(b-1) With regard to a recipient dispute related to a
reduction in or denial of services on the basis of medical
necessity, the commission shall ensure that an independent review
conducted by an independent review organization under this section
occurs after the managed care organization has conducted an
internal appeal and before the Medicaid fair hearing is granted. A
recipient, or the recipient's parent or legally authorized
representative, described by this subsection may opt out of being
subject to an independent review determination under this section
and instead opt to proceed directly to a Medicaid fair hearing.
(c) The commission shall ensure that a contract entered into
under Subsection (b):
(1) requires an independent review organization to
make a review determination in a timely manner as determined by the
commission;
(2) provides procedures to protect the
confidentiality of medical records transmitted to the organization
for use in conducting an independent review;
(3) sets minimum qualifications for and requires the
independence of each physician or other health care provider making
a review determination on behalf of the organization;
(4) subject to Subsection (c-1), specifies the
procedures to be used by the organization in making review
determinations;
(5) requires the timely notice to a recipient of the
results of an independent review, including the clinical basis for
the review determination;
(6) requires that the organization report the
following aggregate information to the commission in the form and
manner and at the times prescribed by the commission:
(A) the number of requests for independent
reviews received by the independent review organization;
(B) the number of independent reviews conducted;
(C) the number of review determinations made:
(i) in favor of a managed care
organization; and
(ii) in favor of a recipient;
(D) the number of review determinations that
resulted in a managed care organization deciding to cover the
service at issue;
(E) a summary of the disputes at issue in
independent reviews;
(F) a summary of the services that were the
subject of independent reviews; and
(G) the average time the organization took to
complete an independent review and make a review determination; and
(7) requires that, in addition to the aggregate
information required by Subdivision (6), the organization include
in the report the information required by that subdivision
categorized by managed care organization.
(c-1) The commission shall establish a common procedure for
independent reviews conducted under this section. The procedure
must provide that a service ordered by a health care provider is
presumed medically necessary and the managed care organization
bears the burden of proof to show the service is not medically
necessary. Medical necessity must be based on publicly available,
up-to-date, evidence-based, and peer-reviewed clinical criteria.
The commission shall also establish a procedure for expedited
reviews that allows the reviewer to identify an appeal that
requires an expedited resolution.
(d) An independent review organization with which the
commission contracts under this section shall:
(1) obtain all information relating to the dispute at
issue from the managed care organization and the provider in
accordance with time frames prescribed by the commission;
(2) assign a physician or other health care provider
with appropriate expertise as a reviewer to make a review
determination;
(3) for each review, perform a check to ensure that the
organization and the physician or other health care provider
assigned to make a review determination do not have a conflict of
interest, as defined in the contract entered into between the
commission and the organization;
(4) communicate procedural rules, approved by the
commission, and other information regarding the appeals process to
all parties; and
(5) render a timely review determination, as
determined by the commission.
(e) The commission shall ensure that the managed care
organization, the provider, and the recipient involved in a dispute
do not have a choice in the reviewer who is assigned to perform the
review.
(e-1) An independent review organization's review
determination of medical necessity establishes the minimum level of
services a recipient must receive.
(f) A managed care organization described by Subsection (b)
may not have a financial relationship with or ownership interest in
an independent review organization with which the commission
contracts. In selecting an independent review organization with
which to contract, the commission shall avoid conflicts of interest
by considering and monitoring existing relationships between
independent review organizations and managed care organizations.
An independent review organization with which the commission
contracts must:
(1) be overseen by a medical director who is a
physician licensed in this state; and
(2) employ or be able to consult with staff with
experience in providing private duty nursing services and long-term
services and supports.
(g) This section does not apply to, and an independent
review organization may not make a review determination with
respect to, a dispute involving the commission's office of
inspector general or an action taken at the direction of that
office, including a dispute relating to:
(1) an action taken by a managed care organization at
the direction of the office under the lock-in program established
in accordance with 42 C.F.R. Part 431.54(e); or
(2) the termination or potential termination of a
provider's enrollment in a managed care organization's provider
network at the direction of the office.
(h) The executive commissioner shall adopt rules necessary
to implement this section.
SECTION 2. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 3. This Act takes effect September 1, 2019.