| 1 | 1 | | 88R1571 MEW-D |
|---|
| 2 | 2 | | By: Muñoz, Jr., Cain H.B. No. 895 |
|---|
| 3 | 3 | | |
|---|
| 4 | 4 | | |
|---|
| 5 | 5 | | A BILL TO BE ENTITLED |
|---|
| 6 | 6 | | AN ACT |
|---|
| 7 | 7 | | relating to the use of extrapolation by a health maintenance |
|---|
| 8 | 8 | | organization or an insurer to audit claims. |
|---|
| 9 | 9 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|---|
| 10 | 10 | | SECTION 1. Section 843.010, Insurance Code, is amended to |
|---|
| 11 | 11 | | read as follows: |
|---|
| 12 | 12 | | Sec. 843.010. APPLICABILITY OF CERTAIN PROVISIONS TO |
|---|
| 13 | 13 | | GOVERNMENTAL HEALTH BENEFIT PLANS. Sections 843.306(f), 843.322, |
|---|
| 14 | 14 | | and 843.363(a)(4) do not apply to coverage under: |
|---|
| 15 | 15 | | (1) the child health plan program under Chapter 62, |
|---|
| 16 | 16 | | Health and Safety Code, or the health benefits plan for children |
|---|
| 17 | 17 | | under Chapter 63, Health and Safety Code; or |
|---|
| 18 | 18 | | (2) a Medicaid program, including a Medicaid managed |
|---|
| 19 | 19 | | care program operated under Chapter 533, Government Code. |
|---|
| 20 | 20 | | SECTION 2. Subchapter I, Chapter 843, Insurance Code, is |
|---|
| 21 | 21 | | amended by adding Section 843.322 to read as follows: |
|---|
| 22 | 22 | | Sec. 843.322. USE OF EXTRAPOLATION PROHIBITED. (a) In this |
|---|
| 23 | 23 | | section, "extrapolation" means a mathematical process or technique |
|---|
| 24 | 24 | | used by a health maintenance organization in the audit of a |
|---|
| 25 | 25 | | participating physician or provider to estimate audit results or |
|---|
| 26 | 26 | | findings for a larger batch or group of claims not reviewed by the |
|---|
| 27 | 27 | | health maintenance organization. |
|---|
| 28 | 28 | | (b) A health maintenance organization may not use |
|---|
| 29 | 29 | | extrapolation to complete an audit of a participating physician or |
|---|
| 30 | 30 | | provider. Any additional payment due a participating physician or |
|---|
| 31 | 31 | | provider or any refund due the health maintenance organization must |
|---|
| 32 | 32 | | be based on the actual overpayment or underpayment and may not be |
|---|
| 33 | 33 | | based on an extrapolation. |
|---|
| 34 | 34 | | SECTION 3. Subchapter B, Chapter 1301, Insurance Code, is |
|---|
| 35 | 35 | | amended by adding Section 1301.0642 to read as follows: |
|---|
| 36 | 36 | | Sec. 1301.0642. USE OF EXTRAPOLATION PROHIBITED. (a) In |
|---|
| 37 | 37 | | this section, "extrapolation" means a mathematical process or |
|---|
| 38 | 38 | | technique used by an insurer in the audit of a preferred provider to |
|---|
| 39 | 39 | | estimate audit results or findings for a larger batch or group of |
|---|
| 40 | 40 | | claims not reviewed by the insurer. |
|---|
| 41 | 41 | | (b) An insurer may not use extrapolation to complete an |
|---|
| 42 | 42 | | audit of a preferred provider. Any additional payment due a |
|---|
| 43 | 43 | | preferred provider or any refund due the insurer must be based on |
|---|
| 44 | 44 | | the actual overpayment or underpayment and may not be based on an |
|---|
| 45 | 45 | | extrapolation. |
|---|
| 46 | 46 | | SECTION 4. The change in law made by this Act applies only |
|---|
| 47 | 47 | | to the audit of a physician or provider under a contract with an |
|---|
| 48 | 48 | | insurer or health maintenance organization entered into or renewed |
|---|
| 49 | 49 | | on or after the effective date of this Act. |
|---|
| 50 | 50 | | SECTION 5. This Act takes effect September 1, 2023. |
|---|