Texas 2023 - 88th Regular

Texas House Bill HB3195 Compare Versions

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1	1	88R1933 SCL-F
2	2	By: Bonnen H.B. No. 3195
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to conduct of insurers providing preferred provider
8	8	benefit plans with respect to physician and health care provider
9	9	contracts and claims.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Sections 1301.066 and 1301.103, Insurance Code,
12	12	are amended to read as follows:
13	13	Sec. 1301.066. RETALIATION AGAINST PREFERRED PROVIDER
14	14	PROHIBITED. (a) An insurer may not engage in any retaliatory action
15	15	against a physician or health care provider[, including terminating
16	16	the physician's or provider's participation in the preferred
17	17	provider benefit plan or refusing to renew the physician's or
18	18	provider's contract,] because the physician or provider has:
19	19	(1) on behalf of an insured, reasonably filed a
20	20	complaint against the insurer; or
21	21	(2) appealed a decision of the insurer.
22	22	(b) A retaliatory action under Subsection (a) includes:
23	23	(1) terminating the physician's or provider's
24	24	participation in the preferred provider benefit plan;
25	25	(2) refusing to renew the physician's or provider's
26	26	contract;
27	27	(3) implementing measurable penalties in the contract
28	28	negotiation process;
29	29	(4) engaging in an unfair or deceptive practice,
30	30	including not listing the physician or provider in the network
31	31	directory or requiring the physician or provider to submit medical
32	32	records with each claim;
33	33	(5) arbitrarily reducing the physician's or provider's
34	34	fees on the insurer's fee schedule; and
35	35	(6) otherwise making changes to material contractual
36	36	terms that are adverse to the physician or provider.
37	37	(c) Subsections (b)(3)-(6) do not apply to a freestanding
38	38	emergency medical care facility.
39	39	Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. (a)
40	40	Except as provided by Sections 1301.104 and 1301.1054, not later
41	41	than the 45th day after the date an insurer receives a clean claim
42	42	from a preferred provider in a nonelectronic format or the 30th day
43	43	after the date an insurer receives a clean claim from a preferred
44	44	provider that is electronically submitted, the insurer shall make a
45	45	determination of whether the claim is payable and:
46	46	(1) if the insurer determines the entire claim is
47	47	payable, pay the total amount of the claim in accordance with the
48	48	contract between the preferred provider and the insurer;
49	49	(2) if the insurer determines a portion of the claim is
50	50	payable, pay the portion of the claim that is not in dispute and
51	51	notify the preferred provider in writing why the remaining portion
52	52	of the claim will not be paid; or
53	53	(3) if the insurer determines that the claim is not
54	54	payable, notify the preferred provider in writing why the claim
55	55	will not be paid.
56	56	(b) An insurer shall provide notice under Subsection (a)
57	57	electronically if the preferred provider's clean claim was
58	58	electronically submitted and the provider is not a freestanding
59	59	emergency medical care facility.
60	60	SECTION 2. Section 1301.105, Insurance Code, is amended by
61	61	amending Subsection (d) and adding Subsection (e) to read as
62	62	follows:
63	63	(d) If the preferred provider does not supply information
64	64	reasonably requested by the insurer in connection with the audit,
65	65	the insurer shall or, if the provider is a freestanding emergency
66	66	medical care facility, may:
67	67	(1) notify the provider in writing that the provider
68	68	must provide the information not later than the 45th day after the
69	69	date of the notice or forfeit the amount of the claim; and
70	70	(2) if the provider does not provide the information
71	71	required by this section, recover the amount of the claim.
72	72	(e) An insurer shall make a request or provide information
73	73	under this section electronically if the preferred provider's clean
74	74	claim was electronically submitted and the provider is not a
75	75	freestanding emergency medical care facility.
76	76	SECTION 3. Sections 1301.1051 and 1301.1052, Insurance
77	77	Code, are amended to read as follows:
78	78	Sec. 1301.1051. COMPLETION OF AUDIT. (a) The insurer must
79	79	complete an audit under Section 1301.105 on or before the 180th day
80	80	after the date the clean claim is received by the insurer, and any
81	81	additional payment due a preferred provider or any refund due the
82	82	insurer shall be made not later than the 30th day after the
83	83	completion of the audit.
84	84	(b) An insurer may not recover a payment on an audited claim
85	85	until a final audit is completed if the claim was submitted by a
86	86	preferred provider other than a freestanding emergency medical care
87	87	facility.
88	88	(c) An insurer shall provide written notice to the preferred
89	89	provider, other than a freestanding emergency medical care
90	90	facility, of the insurer's failure to complete an audit in the time
91	91	required by Subsection (a) not later than the 15th day after the
92	92	date on which the insurer is required to complete the audit under
93	93	that subsection.
94	94	Sec. 1301.1052. PREFERRED PROVIDER APPEAL AFTER AUDIT. (a)
95	95	If a preferred provider disagrees with a refund request made by an
96	96	insurer based on an audit under Section 1301.105, the insurer shall
97	97	provide the provider with an opportunity to appeal in accordance
98	98	with this section, and the insurer may not attempt to recover the
99	99	payment until all appeal rights are exhausted.
100	100	(b) An insurer shall provide a reasonable mechanism for an
101	101	appeal requested under Subsection (a) by a preferred provider other
102	102	than a freestanding emergency medical care facility. The review
103	103	mechanism must incorporate, in an advisory role only, a review
104	104	panel.
105	105	(c) A review panel described by Subsection (b) must be
106	106	composed of at least three preferred provider representatives of
107	107	the same or similar specialty as the affected preferred provider
108	108	selected by the insurer from a list of preferred providers. The
109	109	preferred providers contracting with the insurer in the applicable
110	110	service area shall provide the list of preferred provider
111	111	representatives to the insurer.
112	112	(d) On request and if applicable, the insurer shall provide
113	113	to the affected preferred provider:
114	114	(1) the panel's composition and recommendation; and
115	115	(2) a written explanation of the insurer's
116	116	determination, if that determination is contrary to the panel's
117	117	recommendation.
118	118	SECTION 4. Subchapter C, Chapter 1301, Insurance Code, is
119	119	amended by adding Section 1301.10525 to read as follows:
120	120	Sec. 1301.10525. DEPARTMENT REVIEW OF AUDITS. (a) The
121	121	commissioner by rule shall establish procedures for a preferred
122	122	provider, other than a freestanding emergency medical care
123	123	facility, to submit a request for the department to review an audit
124	124	conducted by an insurer under this subchapter. The department
125	125	review of an audit is a contested case under Chapter 2001,
126	126	Government Code.
127	127	(b) If the department determines that an audit for which a
128	128	preferred provider requested review under Subsection (a) resulted
129	129	in unreasonable costs for the preferred provider, unnecessarily
130	130	delayed or prevented payment of a claim, or otherwise violated this
131	131	subchapter or rules adopted under this subchapter, the department
132	132	shall:
133	133	(1) award compensatory damages to the preferred
134	134	provider incurred as a result of the audit; and
135	135	(2) order the insurer to pay to the department the
136	136	costs incurred by the department in reviewing the audit.
137	137	SECTION 5. Section 1301.132, Insurance Code, is amended by
138	138	adding Subsections (c), (d), and (e) to read as follows:
139	139	(c) An insurer shall provide a reasonable mechanism for an
140	140	appeal requested under Subsection (b) by a physician or health care
141	141	provider other than a freestanding emergency medical care facility.
142	142	The review mechanism must incorporate, in an advisory role only, a
143	143	review panel.
144	144	(d) A review panel described by Subsection (c) must be
145	145	composed of at least three preferred provider representatives of
146	146	the same or similar specialty as the affected preferred provider
147	147	selected by the insurer from a list of preferred providers. The
148	148	preferred providers contracting with the insurer in the applicable
149	149	service area shall provide the list of preferred provider
150	150	representatives to the insurer.
151	151	(e) On request and if applicable, the insurer shall provide
152	152	to the affected preferred provider:
153	153	(1) the panel's composition and recommendation; and
154	154	(2) a written explanation of the insurer's
155	155	determination, if that determination is contrary to the panel's
156	156	recommendation.
157	157	SECTION 6. (a) The changes in law made by this Act apply to
158	158	a claim for payment made on or after the effective date of this Act
159	159	unless the claim is made under a contract that was entered into
160	160	before the effective date of this Act and that, at the time the
161	161	claim is made, has not been renewed or was last renewed before the
162	162	effective date of this Act.
163	163	(b) A claim made before the effective date of this Act or
164	164	made on or after the effective date of this Act under a contract
165	165	described by Subsection (a) of this section is governed by the law
166	166	as it existed immediately before the effective date of this Act, and
167	167	that law is continued in effect for that purpose.
168	168	SECTION 7. This Act takes effect September 1, 2023.