88R9035 SCL/BEE-F
By: Bonnen H.B. No. 4343
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan preauthorization requirements for
certain health care services and 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 4201.653(d), Insurance Code, is amended
to read as follows:
(d) To qualify for an exemption under Subsection (a), a [A]
physician or provider is not required to:
(1) request the [an] exemption; or
(2) perform the health care service that is the
subject of the exemption a minimum number of times [under
Subsection (a) to qualify for the exemption].
SECTION 7. Section 4201.655, Insurance Code, is amended by
amending Subsection (b) and adding Subsection (b-1) to read as
follows:
(b) A determination made under Subsection (a)(2) must be
made by an individual licensed to practice medicine in this state.
For a determination made under Subsection (a)(2) with respect to a
physician, the determination must be made by an individual licensed
to practice medicine in this state who has the same or similar
specialty as that physician. The reviewing physician may not hold a
license to practice administrative medicine under Section 155.009,
Occupations Code.
(b-1) Notwithstanding Subsection (a)(2), if there are fewer
than five claims submitted by the physician or provider during the
most recent evaluation period described by Section 4201.653(b) for
a particular health care service, the health maintenance
organization or insurer shall review all the claims submitted by
the physician or provider during the most recent evaluation period
for that service.
SECTION 8. Section 4201.656(a), Insurance Code, is amended
to read as follows:
(a) A physician or provider has a right to a review of an
adverse determination regarding a preauthorization exemption,
including a health maintenance organization's or insurer's
determination to deny an exemption to the physician or provider
under Section 4201.653, be conducted by an independent review
organization. A health maintenance organization or insurer may not
require a physician or provider to engage in an internal appeal
process before requesting a review by an independent review
organization under this section.
SECTION 9. Sections 4201.659(b) and (c), Insurance Code,
are amended to read as follows:
(b) Regardless of whether an exemption is rescinded after
the provision of a health care service subject to the exemption, a
[A] health maintenance organization or an insurer may not conduct a
utilization [retrospective] review or require another review
similar to preauthorization of the [a health care] service [subject
to an exemption] except:
(1) to determine if the physician or provider still
qualifies for an exemption under this subchapter; or
(2) if the health maintenance organization or insurer
has a reasonable cause to suspect a basis for denial exists under
Subsection (a).
(c) For a utilization [retrospective] review described by
Subsection (b)(2), nothing in this subchapter may be construed to
modify or otherwise affect:
(1) the requirements under or application of Section
4201.305, including any timeframes specified by that section; or
(2) any other applicable law, except to prescribe the
only circumstances under which:
(A) a [retrospective] utilization review may
occur as specified by Subsection (b)(2); or
(B) payment may be denied or reduced as specified
by Subsection (a).
SECTION 10. Subchapter N, Chapter 4201, Insurance Code, is
amended by adding Section 4201.660 to read as follows:
Sec. 4201.660. REPORT. Each health maintenance
organization and insurer shall submit to the department, in the
form and manner prescribed by the commissioner, an annual written
report, for each health care service subject to an exemption under
Section 4201.653, on the:
(1) exemptions granted by the health maintenance
organization or insurer for the service; and
(2) determinations by the health maintenance
organization or insurer to rescind or deny an exemption for the
service.
SECTION 11. 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 12. 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 13. This Act takes effect September 1, 2023.