Texas 2019 - 86th Regular

Texas House Bill HB4572 Compare Versions

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

Old	New	Differences
1	1	By: Raymond H.B. No. 4572
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to the establishment of the independent provider health
7	7	plan monitor for certain appeals in the Medicaid managed care
8	8	program.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 533, Government Code, is amended by
11	11	adding Subchapter F to read as follows:
12	12	SUBCHAPTER F. INDEPENDENT PROVIDER HEALTH PLAN MONITOR
13	13	Sec. 533.301. DEFINITION. In this subchapter, "monitor"
14	14	means the person serving as the independent provider health plan
15	15	monitor under this subchapter.
16	16	Sec. 533.302. ESTABLISHMENT. (a) The commission shall
17	17	establish the position of independent provider health plan monitor
18	18	within the commission.
19	19	(b) The independent provider health plan monitor shall
20	20	create an independent review process that utilizes the standards of
21	21	the Independent Review Organization process under Section
22	22	4202.002, Texas Insurance Code.
23	23	Sec. 533.303. REVIEW OF CORRECTIVE ACTIONS. (a) A health
24	24	care provider in the managed care organization's provider network
25	25	may petition the monitor in the form and manner provided by
26	26	commission rule to review a corrective action taken by a managed
27	27	care organization that is not agreed to by the provider in
28	28	connection with, but not limited to, pre-authorization denials,
29	29	reimbursement, standard of care, a claim payment denial,
30	30	disagreement about medical or treatment necessity, or compliance
31	31	with commission rules and contractual terms.
32	32	(b) The monitor shall review a case submitted under
33	33	Subsection (a) and issue a decision in accordance with this
34	34	subchapter.
35	35	Sec. 533.304. PROCEDURES. (a) The monitor shall:
36	36	(1) provide written notice of the submission of a
37	37	petition under Section 533.303 to the party opposing the party that
38	38	submitted the petition; and
39	39	(2) allow the opposing party to submit evidence to the
40	40	monitor not later than the:
41	41	(A) 10th day after the monitor provided the
42	42	notice for petitions involving pre-authorizations, or medical or
43	43	treatment necessity denials, or
44	44	(B) 30th day after the date the monitor provided
45	45	the notice for all other petitions.
46	46	(b) Not later than the 30th day after the deadline for the
47	47	submission of evidence under Subsection (a), the monitor shall
48	48	provide written notice to the parties of the monitor's decision for
49	49	the case.
50	50	(c) While the review process or an appeal by either a
51	51	provider or the managed care organization is ongoing, the managed
52	52	care organization shall not recoup any funds or otherwise penalize
53	53	a provider.
54	54	(d) In reaching a decision under Subsection (b), the monitor
55	55	shall conduct interviews with all relevant parties and review any
56	56	submitted documentation and other evidence to determine whether:
57	57	(1) the managed care organization complied with:
58	58	(A) applicable commission rules; and
59	59	(B) the organization's internal policies
60	60	and procedures for auditing or taking a corrective action against a
61	61	health care provider; and
62	62	(2) the health care provider:
63	63	(A) complied with applicable commission
64	64	rules;
65	65	(B) submitted required documentation in
66	66	accordance with the law; and
67	67	(C) engaged with a recipient.
68	68	(e) The decision made by the monitor shall be binding unless
69	69	appealed by the provider or the managed care organization.
70	70	(f) An adverse decision against a managed care organization
71	71	shall be registered as a verified complaint within the commission's
72	72	system and shall be subject to any appropriate penalties by the
73	73	commission.
74	74	(g) An adverse decision against a managed care organization
75	75	shall be subject to the prompt payment penalty from the beginning
76	76	date of the late payment.
77	77	Sec. 533.305. APPEAL. A managed care organization or
78	78	health care provider may appeal the monitor's decision under
79	79	Section 533.304 to the State Office of Administrative Hearings.
80	80	Sec. 533.306. REPORT. The monitor shall compile and
81	81	provide an annual report to the commission on:
82	82	(1) the number of corrective actions reviewed by the
83	83	monitor for which petitions were submitted by a health care
84	84	provider;
85	85	(2) the number of corrective actions reviewed by the
86	86	monitor for which petitions were submitted by a managed care
87	87	organization;
88	88	(3) the number of corrective actions overturned by the
89	89	monitor;
90	90	(4) the number of corrective actions upheld by the
91	91	monitor;
92	92	(5) the reasons for submissions by health care
93	93	providers of petitions to the monitor;
94	94	(6) the amount of money managed care organizations
95	95	recovered in corrective actions upheld by the monitor; and
96	96	(7) the amount of money reimbursed to health care
97	97	providers through corrective actions overturned by the monitor.
98	98	SECTION 2. As soon as practicable after the effective date
99	99	of this Act, the executive commissioner of the Health and Human
100	100	Services Commission shall adopt rules necessary to implement
101	101	Subchapter F, Chapter 533, Government Code, as added by this Act,
102	102	and the commission shall establish the position of independent
103	103	provider health plan monitor under that subchapter.
104	104	SECTION 3. If before implementing any provision of this Act
105	105	a state agency determines that a waiver or authorization from a
106	106	federal agency is necessary for implementation of that provision,
107	107	the agency affected by the provision shall request the waiver or
108	108	authorization and may delay implementing that provision until the
109	109	waiver or authorization is granted.
110	110	SECTION 4. This Act takes effect September 1, 2019.