Texas 2021 - 87th Regular

Texas House Bill HB2929 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		87R19181 SCL-F
2	2		By: Bonnen, Frank H.B. No. 2929
	3	+	Substitute the following for H.B. No. 2929:
	4	+	By: Oliverson C.S.H.B. No. 2929
3	5
4	6
5	7		A BILL TO BE ENTITLED
6	8		AN ACT
7	9		relating to conduct of insurers providing preferred provider
8	10		benefit plans with respect to physician and health care provider
9	11		contracts and claims.
10	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	13		SECTION 1. Sections 1301.066 and 1301.103, Insurance Code,
12	14		are amended to read as follows:
13	15		Sec. 1301.066. RETALIATION AGAINST PREFERRED PROVIDER
14	16		PROHIBITED. (a) An insurer may not engage in any retaliatory action
15	17		against a physician or health care provider[, including terminating
16	18		the physician's or provider's participation in the preferred
17	19		provider benefit plan or refusing to renew the physician's or
18	20		provider's contract,] because the physician or provider has:
19	21		(1) on behalf of an insured, reasonably filed a
20	22		complaint against the insurer; or
21	23		(2) appealed a decision of the insurer.
22	24		(b) A retaliatory action under Subsection (a) includes:
23	25		(1) terminating the physician's or provider's
24	26		participation in the preferred provider benefit plan;
25	27		(2) refusing to renew the physician's or provider's
26	28		contract;
27	29		(3) implementing measurable penalties in the contract
28	30		negotiation process;
29	31		(4) engaging in an unfair or deceptive practice,
30	32		including not listing the physician or provider in the network
31	33		directory or requiring the physician or provider to submit medical
32	34		records with each claim;
33	35		(5) arbitrarily reducing the physician's or provider's
34	36		fees on the insurer's fee schedule; and
35	37		(6) otherwise making changes to material contractual
36	38		terms that are adverse to the physician or provider.
37	39		Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. (a)
38	40		Except as provided by Sections 1301.104 and 1301.1054, not later
39	41		than the 45th day after the date an insurer receives a clean claim
40	42		from a preferred provider in a nonelectronic format or the 30th day
41	43		after the date an insurer receives a clean claim from a preferred
42	44		provider that is electronically submitted, the insurer shall make a
43	45		determination of whether the claim is payable and:
44	46		(1) if the insurer determines the entire claim is
45	47		payable, pay the total amount of the claim in accordance with the
46	48		contract between the preferred provider and the insurer;
47	49		(2) if the insurer determines a portion of the claim is
48	50		payable, pay the portion of the claim that is not in dispute and
49	51		notify the preferred provider in writing why the remaining portion
50	52		of the claim will not be paid; or
51	53		(3) if the insurer determines that the claim is not
52	54		payable, notify the preferred provider in writing why the claim
53	55		will not be paid.
54	56		(b) An insurer shall provide notice under Subsection (a)
55	57		electronically if the preferred provider's clean claim was
56	58		electronically submitted.
57	59		SECTION 2. Section 1301.105, Insurance Code, is amended by
58	60		amending Subsection (d) and adding Subsection (e) to read as
59	61		follows:
60	62		(d) If the preferred provider does not supply information
61	63		reasonably requested by the insurer in connection with the audit,
62	64		the insurer shall [may]:
63	65		(1) notify the provider in writing that the provider
64	66		must provide the information not later than the 45th day after the
65	67		date of the notice or forfeit the amount of the claim; and
66	68		(2) if the provider does not provide the information
67	69		required by this section, recover the amount of the claim.
68	70		(e) An insurer shall make a request or provide information
69	71		under this section electronically if the preferred provider's clean
70	72		claim was electronically submitted.
71	73		SECTION 3. Sections 1301.1051 and 1301.1052, Insurance
72	74		Code, are amended to read as follows:
73	75		Sec. 1301.1051. COMPLETION OF AUDIT. (a) The insurer must
74	76		complete an audit under Section 1301.105 on or before the 180th day
75	77		after the date the clean claim is received by the insurer, and any
76	78		additional payment due a preferred provider or any refund due the
77	79		insurer shall be made not later than the 30th day after the
78	80		completion of the audit.
79	81		(b) An insurer may not recover a payment on an audited claim
80	82		until a final audit is completed.
81	83		(c) An insurer shall provide written notice to the preferred
82	84		provider of the insurer's failure to complete an audit in the time
83	85		required by Subsection (a) not later than the 15th day after the
84	86		date on which the insurer is required to complete the audit under
85	87		that subsection.
86	88		Sec. 1301.1052. PREFERRED PROVIDER APPEAL AFTER AUDIT. (a)
87	89		If a preferred provider disagrees with a refund request made by an
88	90		insurer based on an audit under Section 1301.105, the insurer shall
89	91		provide the provider with an opportunity to appeal in accordance
90	92		with this section, and the insurer may not attempt to recover the
91	93		payment until all appeal rights are exhausted.
92	94		(b) An insurer shall provide a reasonable mechanism for an
93	95		appeal requested under Subsection (a). The review mechanism must
94	96		incorporate, in an advisory role only, a review panel.
95	97		(c) A review panel described by Subsection (b) must be
96	98		composed of at least three preferred provider representatives of
97	99		the same or similar specialty as the affected preferred provider
98	100		selected by the insurer from a list of preferred providers. The
99	101		preferred providers contracting with the insurer in the applicable
100	102		service area shall provide the list of preferred provider
101	103		representatives to the insurer.
102	104		(d) On request, the insurer shall provide to the affected
103	105		preferred provider:
104	106		(1) the panel's composition and recommendation; and
105	107		(2) a written explanation of the insurer's
106	108		determination, if that determination is contrary to the panel's
107	109		recommendation.
108	110		SECTION 4. Subchapter C, Chapter 1301, Insurance Code, is
109	111		amended by adding Section 1301.10525 to read as follows:
110	112		Sec. 1301.10525. DEPARTMENT REVIEW OF AUDITS. (a) The
111	113		commissioner by rule shall establish procedures for a preferred
112	114		provider to submit a request for the department to review an audit
113	115		conducted by an insurer under this subchapter. The department
114	116		review of an audit is a contested case under Chapter 2001,
115	117		Government Code.
116	118		(b) If the department determines that an audit for which a
117	119		preferred provider requested review resulted in unreasonable costs
118	120		for the preferred provider, unnecessarily delayed or prevented
119	121		payment of a claim, or otherwise violated this subchapter or rules
120	122		adopted under this subchapter, the department shall:
121	123		(1) award compensatory damages to the preferred
122	124		provider incurred as a result of the audit; and
123	125		(2) order the insurer to pay to the department the
124	126		costs incurred by the department in reviewing the audit.
125	127		SECTION 5. Section 1301.132, Insurance Code, is amended by
126	128		adding Subsections (c), (d), and (e) to read as follows:
127	129		(c) An insurer shall provide a reasonable mechanism for an
128	130		appeal requested under Subsection (b). The review mechanism must
129	131		incorporate, in an advisory role only, a review panel.
130	132		(d) A review panel described by Subsection (c) must be
131	133		composed of at least three preferred provider representatives of
132	134		the same or similar specialty as the affected preferred provider
133	135		selected by the insurer from a list of preferred providers. The
134	136		preferred providers contracting with the insurer in the applicable
135	137		service area shall provide the list of preferred provider
136	138		representatives to the insurer.
137	139		(e) On request, the insurer shall provide to the affected
138	140		preferred provider:
139	141		(1) the panel's composition and recommendation; and
140	142		(2) a written explanation of the insurer's
141	143		determination, if that determination is contrary to the panel's
142	144		recommendation.
143	145		SECTION 6. (a) The changes in law made by this Act apply to
144	146		a claim for payment made on or after the effective date of this Act
145	147		unless the claim is made under a contract that was entered into
146	148		before the effective date of this Act and that, at the time the
147	149		claim is made, has not been renewed or was last renewed before the
148	150		effective date of this Act.
149	151		(b) A claim made before the effective date of this Act or
150	152		made on or after the effective date of this Act under a contract
151	153		described by Subsection (a) of this section is governed by the law
152	154		as it existed immediately before the effective date of this Act, and
153	155		that law is continued in effect for that purpose.
154	156		SECTION 7. This Act takes effect September 1, 2021.