88R4688 BEE/SCL-D
By: Bonnen H.B. No. 4326
A BILL TO BE ENTITLED
AN ACT
relating to the direction of utilization review by physicians.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 4201.152, Insurance Code, is amended to
read as follows:
Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF
PHYSICIAN. A utilization review agent shall conduct utilization
review under the direction of a physician licensed to practice
medicine in this state. The physician may not hold a license to
practice administrative medicine under Section 155.009,
Occupations Code.
SECTION 2. Subchapter M, Chapter 4201, Insurance Code, is
amended by adding Section 4201.6015 to read as follows:
Sec. 4201.6015. INQUIRY BY TEXAS MEDICAL BOARD. (a) If the
Texas Medical Board believes that a physician has directed a
utilization review in an arbitrary manner or without a medical
basis or receives a complaint with that allegation, the Texas
Medical Board:
(1) shall notify the physician of the allegation; and
(2) may compel the production of documents or other
information as necessary to determine whether the utilization
review was directed in an arbitrary manner or without a medical
basis.
(b) An inquiry and determination under this section is
limited to whether the utilization review was directed in an
arbitrary manner or without a medical basis in accordance with the
standards of medical practice. If the commissioner initiates a
proceeding under Section 4201.601 in relation to the same
utilization review for which the inquiry is being conducted, the
Texas Medical Board shall suspend the inquiry until the conclusion
of the commissioner's proceeding.
SECTION 3. The heading to Section 4201.602, Insurance Code,
is amended to read as follows:
Sec. 4201.602. ENFORCEMENT PROCEEDINGS [PROCEEDING].
SECTION 4. Section 4201.602(a), Insurance Code, is amended
to read as follows:
(a) The commissioner may initiate a proceeding under
Section 4201.601 [this subchapter]. The Texas Medical Board may
initiate a proceeding under Section 4201.6015.
SECTION 5. Section 4201.603, Insurance Code, is amended to
read as follows:
Sec. 4201.603. REMEDIES AND PENALTIES; EMERGENCY REMEDIES
[FOR VIOLATION]. (a) If the commissioner determines that a
utilization review agent, health maintenance organization,
insurer, or other person or entity conducting utilization review
has violated or is violating this chapter, the commissioner may:
(1) impose a sanction under Chapter 82;
(2) issue a cease and desist order under Chapter 83; or
(3) assess an administrative penalty under Chapter 84.
(b) The Texas Medical Board may restrict, suspend, or revoke
the license of a physician the board determines has directed a
utilization review in an arbitrary manner or without a medical
basis at the conclusion of a proceeding conducted under Section
4201.6015.
(c) If a utilization review results in the serious injury or
death of the individual who is the subject of the review, the
commissioner may temporarily prohibit a physician who directed the
review from directing utilization review and the Texas Medical
Board may temporarily suspend the physician's license. The
commissioner or Texas Medical Board, as applicable, shall conduct a
proceeding under Section 4201.601 or 4201.6015, as applicable,
regarding the utilization review, and the prohibition or suspension
is effective until the conclusion of the proceeding.
SECTION 6. Section 151.002(a)(13), Occupations Code, is
amended to read as follows:
(13) "Practicing medicine" means:
(A) the diagnosis, treatment, or offer to treat a
mental or physical disease or disorder or a physical deformity or
injury by any system or method, or the attempt to effect cures of
those conditions, by a person who:
(i) [(A)] publicly professes to be a
physician or surgeon; or
(ii) [(B)] directly or indirectly charges
money or other compensation for those services; and
(B) the direction of utilization review
conducted by a utilization review agent under Section 4201.152,
Insurance Code.
SECTION 7. The change in law made by this Act applies only
to utilization review conducted on or after the effective date of
this Act. Utilization review conducted before the effective date of
this Act is governed by the law as it existed immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.
SECTION 8. This Act takes effect September 1, 2023.