Texas 2023 - 88th Regular

Texas House Bill HB4343 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	88R23852 SCL/BEE-F
2	2	By: Bonnen H.B. No. 4343
3	3	Substitute the following for H.B. No. 4343:
4	4	By: Klick C.S.H.B. No. 4343
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to health benefit plan preauthorization requirements for
10	10	certain health care services and the direction of utilization
11	11	review by physicians.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Section 4201.152, Insurance Code, is amended to
14	14	read as follows:
15	15	Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF
16	16	PHYSICIAN. A utilization review agent shall conduct utilization
17	17	review under the direction of a physician licensed to practice
18	18	medicine in this state. The physician may not hold a license to
19	19	practice administrative medicine under Section 155.009,
20	20	Occupations Code.
21	21	SECTION 2. Subchapter M, Chapter 4201, Insurance Code, is
22	22	amended by adding Section 4201.6015 to read as follows:
23	23	Sec. 4201.6015. INQUIRY BY TEXAS MEDICAL BOARD. (a) This
24	24	section does not apply to chiropractic treatments.
25	25	(b) If the Texas Medical Board believes that a physician has
26	26	directed a utilization review in an arbitrary manner or without a
27	27	medical basis or receives a complaint with that allegation, the
28	28	Texas Medical Board may request the department to determine whether
29	29	the health insurance policy or health benefit plan that is the
30	30	subject of the utilization review covers the health care service
31	31	being reviewed.
32	32	(c) If the department determines the health care service is
33	33	covered under Subsection (b), the Texas Medical Board:
34	34	(1) shall notify the physician of the allegation; and
35	35	(2) may compel the production of documents or other
36	36	information as necessary to determine whether the utilization
37	37	review was directed in an arbitrary manner or without a medical
38	38	basis.
39	39	(d) An inquiry and determination under this section is
40	40	limited to whether the utilization review was directed in an
41	41	arbitrary manner or without a medical basis in accordance with the
42	42	standards of medical practice. If the commissioner initiates a
43	43	proceeding under Section 4201.601 in relation to the same
44	44	utilization review for which the inquiry is being conducted, the
45	45	Texas Medical Board shall suspend the inquiry until the conclusion
46	46	of the commissioner's proceeding.
47	47	(e) The Texas Medical Board may conduct an inquiry under
48	48	this section in the manner provided by Section 154.0561,
49	49	Occupations Code.
50	50	SECTION 3. The heading to Section 4201.602, Insurance Code,
51	51	is amended to read as follows:
52	52	Sec. 4201.602. ENFORCEMENT PROCEEDINGS [PROCEEDING].
53	53	SECTION 4. Section 4201.602(a), Insurance Code, is amended
54	54	to read as follows:
55	55	(a) The commissioner may initiate a proceeding under
56	56	Section 4201.601 [this subchapter]. The Texas Medical Board may
57	57	initiate a proceeding under Section 4201.6015.
58	58	SECTION 5. Section 4201.603, Insurance Code, is amended to
59	59	read as follows:
60	60	Sec. 4201.603. REMEDIES AND PENALTIES; EMERGENCY REMEDIES
61	61	[FOR VIOLATION]. (a) If the commissioner determines that a
62	62	utilization review agent, health maintenance organization,
63	63	insurer, or other person or entity conducting utilization review
64	64	has violated or is violating this chapter, the commissioner may:
65	65	(1) impose a sanction under Chapter 82;
66	66	(2) issue a cease and desist order under Chapter 83; or
67	67	(3) assess an administrative penalty under Chapter 84.
68	68	(b) The Texas Medical Board may restrict, suspend, or revoke
69	69	the license of a physician the board determines has directed a
70	70	utilization review in an arbitrary manner or without a medical
71	71	basis at the conclusion of a proceeding conducted under Section
72	72	4201.6015.
73	73	(c) If a utilization review results in the serious injury or
74	74	death of the individual who is the subject of the review, the
75	75	commissioner may temporarily prohibit a physician who directed the
76	76	review from directing utilization review and the Texas Medical
77	77	Board may temporarily suspend the physician's license. The
78	78	commissioner or Texas Medical Board, as applicable, shall conduct a
79	79	proceeding under Section 4201.601 or 4201.6015, as applicable,
80	80	regarding the utilization review, and the prohibition or suspension
81	81	is effective until the conclusion of the proceeding.
82	82	SECTION 6. Section 4201.651(a), Insurance Code, is amended
83	83	to read as follows:
84	84	(a) In this subchapter:
85	85	(1) "Affiliate" has the meaning assigned by Section
86	86	823.003.
87	87	(2) "Preauthorization"[, "preauthorization"] means a
88	88	determination by a health maintenance organization, insurer, or
89	89	person contracting with a health maintenance organization or
90	90	insurer that health care services proposed to be provided to a
91	91	patient are medically necessary and appropriate.
92	92	SECTION 7. Section 4201.653, Insurance Code, is amended by
93	93	amending Subsections (a) and (b) and adding Subsection (a-1) to
94	94	read as follows:
95	95	(a) A health maintenance organization or an insurer that
96	96	uses a preauthorization process for health care services may not
97	97	require a physician or provider to obtain preauthorization for a
98	98	particular health care service if, in the most recent one-year
99	99	[six-month] evaluation period, as described by Subsection (b), the
100	100	health maintenance organization or insurer, including any
101	101	affiliate, has approved or would have approved not less than 90
102	102	percent of the preauthorization requests submitted by the physician
103	103	or provider for the particular health care service.
104	104	(a-1) In conducting an evaluation for an exemption under
105	105	this section, a health maintenance organization or insurer must
106	106	include all preauthorization requests submitted by a physician or
107	107	provider to the health maintenance organization or insurer, or its
108	108	affiliate, considering all health insurance policies and health
109	109	benefit plans issued or administered by the health maintenance
110	110	organization or insurer, or its affiliate, regardless of whether
111	111	the preauthorization request was made in connection with a health
112	112	insurance policy or health benefit plan that is subject to this
113	113	subchapter.
114	114	(b) Except as provided by Subsection (c), a health
115	115	maintenance organization or insurer shall evaluate whether a
116	116	physician or provider qualifies for an exemption from
117	117	preauthorization requirements under Subsection (a) once every year
118	118	[six months].
119	119	SECTION 8. Section 4201.655, Insurance Code, is amended by
120	120	amending Subsection (b) and adding Subsection (b-1) to read as
121	121	follows:
122	122	(b) A determination made under Subsection (a)(2) must be
123	123	made by an individual licensed to practice medicine in this state.
124	124	For a determination made under Subsection (a)(2) with respect to a
125	125	physician, the determination must be made by an individual licensed
126	126	to practice medicine in this state who has the same or similar
127	127	specialty as that physician. The reviewing physician may not hold a
128	128	license to practice administrative medicine under Section 155.009,
129	129	Occupations Code.
130	130	(b-1) Notwithstanding Subsection (a)(2), if there are fewer
131	131	than five claims submitted by the physician or provider during the
132	132	most recent evaluation period described by Section 4201.653(b) for
133	133	a particular health care service, the health maintenance
134	134	organization or insurer shall review all the claims submitted by
135	135	the physician or provider during the most recent evaluation period
136	136	for that service.
137	137	SECTION 9. Section 4201.656(a), Insurance Code, is amended
138	138	to read as follows:
139	139	(a) A physician or provider has a right to a review of an
140	140	adverse determination regarding a preauthorization exemption,
141	141	including a health maintenance organization's or insurer's
142	142	determination to deny an exemption to the physician or provider
143	143	under Section 4201.653, to be conducted by an independent review
144	144	organization. A health maintenance organization or insurer may not
145	145	require a physician or provider to engage in an internal appeal
146	146	process before requesting a review by an independent review
147	147	organization under this section.
148	148	SECTION 10. Sections 4201.659(b) and (c), Insurance Code,
149	149	are amended to read as follows:
150	150	(b) Regardless of whether an exemption is rescinded after
151	151	the provision of a health care service subject to the exemption, a
152	152	[A] health maintenance organization or an insurer may not conduct a
153	153	utilization [retrospective] review or require another review
154	154	similar to preauthorization of the [a health care] service [subject
155	155	to an exemption] except:
156	156	(1) to determine if the physician or provider still
157	157	qualifies for an exemption under this subchapter; or
158	158	(2) if the health maintenance organization or insurer
159	159	has a reasonable cause to suspect a basis for denial exists under
160	160	Subsection (a).
161	161	(c) For a utilization [retrospective] review described by
162	162	Subsection (b)(2), nothing in this subchapter may be construed to
163	163	modify or otherwise affect:
164	164	(1) the requirements under or application of Section
165	165	4201.305, including any timeframes specified by that section; or
166	166	(2) any other applicable law, except to prescribe the
167	167	only circumstances under which:
168	168	(A) a [retrospective] utilization review may
169	169	occur as specified by Subsection (b)(2); or
170	170	(B) payment may be denied or reduced as specified
171	171	by Subsection (a).
172	172	SECTION 11. Subchapter N, Chapter 4201, Insurance Code, is
173	173	amended by adding Section 4201.660 to read as follows:
174	174	Sec. 4201.660. REPORT. (a) Each health maintenance
175	175	organization and insurer shall submit to the department, in the
176	176	form and manner prescribed by the commissioner, an annual written
177	177	report, for each health care service subject to an exemption under
178	178	Section 4201.653, on the:
179	179	(1) exemptions granted by the health maintenance
180	180	organization or insurer for the service; and
181	181	(2) determinations by the health maintenance
182	182	organization or insurer to rescind or deny an exemption for the
183	183	service.
184	184	(b) Subject to this subsection, a report submitted under
185	185	Subsection (a) is public information subject to disclosure under
186	186	Chapter 552, Government Code. The department shall ensure that the
187	187	report does not contain any identifying information before
188	188	disclosing the report in accordance with Chapter 552, Government
189	189	Code.
190	190	SECTION 12. Section 151.002(a)(13), Occupations Code, is
191	191	amended to read as follows:
192	192	(13) "Practicing medicine" means:
193	193	(A) the diagnosis, treatment, or offer to treat a
194	194	mental or physical disease or disorder or a physical deformity or
195	195	injury by any system or method, or the attempt to effect cures of
196	196	those conditions, by a person who:
197	197	(i) [(A)] publicly professes to be a
198	198	physician or surgeon; or
199	199	(ii) [(B)] directly or indirectly charges
200	200	money or other compensation for those services; and
201	201	(B) the direction of utilization review
202	202	conducted by a utilization review agent under Section 4201.152,
203	203	Insurance Code.
204	204	SECTION 13. (a) The change in law made by this Act applies
205	205	only to utilization review conducted on or after the effective date
206	206	of this Act. Utilization review conducted before the effective date
207	207	of this Act is governed by the law as it existed immediately before
208	208	the effective date of this Act, and that law is continued in effect
209	209	for that purpose.
210	210	(b) A preauthorization exemption provided under Section
211	211	4201.653, Insurance Code, before the effective date of this Act may
212	212	not be rescinded before the first anniversary of the last day of the
213	213	most recent evaluation period for the exemption.
214	214	SECTION 14. This Act takes effect September 1, 2023.