88R23304 CJD-F
By: Harris of Williamson H.B. No. 3351
A BILL TO BE ENTITLED
AN ACT
relating to standards required for certain rankings of physicians
by health benefit plan issuers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1460.003, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (a-1) to read as
follows:
(a) A health benefit plan issuer, including a subsidiary or
affiliate, may not rank physicians or[,] classify physicians into
tiers based on performance[, or publish physician-specific
information that includes rankings, tiers, ratings, or other
comparisons of a physician's performance against standards,
measures, or other physicians,] unless:
(1) the standards used by the health benefit plan
issuer to rank or classify are propagated or developed by an
organization designated by the commissioner through rules adopted
under Section 1460.005;
(2) the ranking, comparison, or evaluation:
(A) is disclosed to each affected physician at
least 45 days before the date the ranking, comparison, or
evaluation is released, published, or distributed to enrollees by
the health benefit plan issuer; and
(B) identifies which products or networks
offered by the health benefit plan issuer the ranking, comparison,
or evaluation will be used for; and
(3) each affected physician is given an easy-to-use
process to identify discrepancies between the standards and the
ranking, comparison, or evaluation as propagated by the health
benefit plan issuer [the standards used by the health benefit plan
issuer conform to nationally recognized standards and guidelines as
required by rules adopted under Section 1460.005;
[(2) the standards and measurements to be used by the
health benefit plan issuer are disclosed to each affected physician
before any evaluation period used by the health benefit plan
issuer; and
[(3) each affected physician is afforded, before any
publication or other public dissemination, an opportunity to
dispute the ranking or classification through a process that, at a
minimum, includes due process protections that conform to the
following protections:
[(A) the health benefit plan issuer provides at
least 45 days' written notice to the physician of the proposed
rating, ranking, tiering, or comparison, including the
methodologies, data, and all other information utilized by the
health benefit plan issuer in its rating, tiering, ranking, or
comparison decision;
[(B) in addition to any written fair
reconsideration process, the health benefit plan issuer, upon a
request for review that is made within 30 days of receiving the
notice under Paragraph (A), provides a fair reconsideration
proceeding, at the physician's option:
[(i) by teleconference, at an agreed upon
time; or
[(ii) in person, at an agreed upon time or
between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
[(C) the physician has the right to provide
information at a requested fair reconsideration proceeding for
determination by a decision-maker, have a representative
participate in the fair reconsideration proceeding, and submit a
written statement at the conclusion of the fair reconsideration
proceeding; and
[(D) the health benefit plan issuer provides a
written communication of the outcome of a fair reconsideration
proceeding prior to any publication or dissemination of the rating,
ranking, tiering, or comparison. The written communication must
include the specific reasons for the final decision].
(a-1) If a physician submits information to a health benefit
plan issuer under Subsection (a)(3) sufficient to establish a
discrepancy, the health benefit plan issuer must remedy the
discrepancy by the later of:
(1) publication; or
(2) the 30th day after the date the health benefit plan
issuer receives the information.
SECTION 2. Section 1460.005(c), Insurance Code, is amended
to read as follows:
(c) In adopting rules under this section, the commissioner
may only designate [shall consider the standards, guidelines, and
measures prescribed by nationally recognized] organizations that
meet the following requirements:
(1) the prescribing organization is bona fide and
unbiased toward or against any medical provider;
(2) the standards to be used in rankings, comparisons,
or evaluations:
(A) are nationally recognized, or based on
expert-provider consensus or leading clinical evidence-based
scholarship;
(B) have a publicly transparent methodology; and
(C) if based on clinical outcomes, are
risk-adjusted; and
(3) the prescribing organization has an easy-to-use
process by which a medical provider may report data, evidentiary,
factual, or mathematical errors for prompt investigation and, if
appropriate, correction [establish or promote guidelines and
performance measures emphasizing quality of health care, including
the National Quality Forum and the AQA Alliance. If neither the
National Quality Forum nor the AQA Alliance has established
standards or guidelines regarding an issue, the commissioner shall
consider the standards, guidelines, and measures prescribed by the
National Committee on Quality Assurance and other similar national
organizations. If neither the National Quality Forum, nor the AQA
Alliance, nor other national organizations have established
standards or guidelines regarding an issue, the commissioner shall
consider standards, guidelines, and measures based on other bona
fide nationally recognized guidelines, expert-based physician
consensus quality standards, or leading objective clinical
evidence and scholarship].
SECTION 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2023.