Texas 2019 - 86th Regular

Texas Senate Bill SB1419 Compare Versions

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

Old	New	Differences
1	1	By: Rodríguez S.B. No. 1419
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
38	38	opposing the party that submitted the petition;
39	39	and
40	40	(2) allow the opposing party to submit evidence to the
41	41	monitor not later than the:
42	42	(A) 10th day after the monitor provided the
43	43	notice for petitions involving
44	44	pre-authorizations, or medical or treatment
45	45	necessity denials, or
46	46	(B) 30th day after the date the monitor provided
47	47	the notice for all other petitions.
48	48	(b) Not later than the 30th day after the deadline for the
49	49	submission of evidence under Subsection (a), the monitor shall
50	50	provide written notice to the parties of the monitor's decision for
51	51	the case.
52	52	(c) While the review process or an appeal by either a
53	53	provider or the managed care organization is ongoing, the managed
54	54	care organization shall not recoup any funds or otherwise penalize
55	55	a provider.
56	56	(d) In reaching a decision under Subsection (b), the monitor
57	57	shall conduct interviews with all relevant parties and review any
58	58	submitted documentation and other evidence to determine whether:
59	59	(1) the managed care organization complied with:
60	60	(A) applicable commission rules; and
61	61	(B) the organization's internal policies and
62	62	procedures for auditing or taking a corrective action against a
63	63	health care provider; and
64	64	(2) the health care provider:
65	65	(A) complied with applicable commission rules;
66	66	(B) submitted required documentation in
67	67	accordance with the law; and
68	68	(C) engaged with a recipient.
69	69	(e) The decision made by the monitor shall be binding unless
70	70	appealed by the provider or the managed care organization.
71	71	(f) An adverse decision against a managed care organization
72	72	shall be registered as a verified complaint within the commission's
73	73	system and shall be subject to any appropriate penalties by the
74	74	commission.
75	75	(g) An adverse decision against a managed care organization
76	76	shall be subject to the prompt payment penalty from the beginning
77	77	date of the late payment.
78	78	Sec. 533.305. APPEAL. A managed care organization or
79	79	health care provider may appeal the monitor's decision under
80	80	Section 533.304 to the State Office of Administrative Hearings.
81	81	Sec. 533.306. REPORT. The monitor shall compile and
82	82	provide an annual report to the commission on:
83	83	(1) the number of corrective actions reviewed by the
84	84	monitor for which petitions were submitted by a health care
85	85	provider;
86	86	(2) the number of corrective actions reviewed by the
87	87	monitor for which petitions were submitted by a managed care
88	88	organization;
89	89	(3) the number of corrective actions overturned by the
90	90	monitor;
91	91	(4) the number of corrective actions upheld by the
92	92	monitor;
93	93	(5) the reasons for submissions by health care
94	94	providers of petitions to the monitor;
95	95	(6) the amount of money managed care organizations
96	96	recovered in corrective actions upheld by the monitor; and
97	97	(7) the amount of money reimbursed to health care
98	98	providers through corrective actions overturned by the monitor.
99	99	SECTION 2. As soon as practicable after the effective date
100	100	of this Act, the executive commissioner of the Health and Human
101	101	Services Commission shall adopt rules necessary to implement
102	102	Subchapter F, Chapter 533, Government Code, as added by this Act,
103	103	and the commission shall establish the position of independent
104	104	provider health plan monitor under that subchapter.
105	105	SECTION 3. If before implementing any provision of this Act
106	106	a state agency determines that a waiver or authorization from a
107	107	federal agency is necessary for implementation of that provision,
108	108	the agency affected by the provision shall request the waiver or
109	109	authorization and may delay implementing that provision until the
110	110	waiver or authorization is granted.
111	111	SECTION 4. This Act takes effect September 1, 2019.