Bill Text: TX HB2151 | 2019-2020 | 86th Legislature | Engrossed
Bill Title: Relating to the use of extrapolation by a health maintenance organization or an insurer to audit claims.
Spectrum: Slight Partisan Bill (Democrat 3-1)
Status: (Engrossed - Dead) 2019-05-15 - Referred to Business & Commerce [HB2151 Detail]
Download: Texas-2019-HB2151-Engrossed.html
| By: Muñoz, Jr., Martinez, Guillen, Guerra | H.B. No. 2151 | |
|
|
||
|
|
||
| relating to the use of extrapolation by a health maintenance | ||
| organization or an insurer to audit claims. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. Section 843.010, Insurance Code, is amended to | ||
| read as follows: | ||
| Sec. 843.010. APPLICABILITY OF CERTAIN PROVISIONS TO | ||
| GOVERNMENTAL HEALTH BENEFIT PLANS. Sections 843.306(f), 843.322, | ||
| and 843.363(a)(4) do not apply to coverage under: | ||
| (1) the child health plan program under Chapter 62, | ||
| Health and Safety Code, or the health benefits plan for children | ||
| under Chapter 63, Health and Safety Code; or | ||
| (2) a Medicaid program, including a Medicaid managed | ||
| care program operated under Chapter 533, Government Code. | ||
| SECTION 2. Subchapter I, Chapter 843, Insurance Code, is | ||
| amended by adding Section 843.322 to read as follows: | ||
| Sec. 843.322. USE OF EXTRAPOLATION PROHIBITED. (a) In this | ||
| section, "extrapolation" means a mathematical process or technique | ||
| used by a health maintenance organization in the audit of a | ||
| participating physician or provider to estimate audit results or | ||
| findings for a larger batch or group of claims not reviewed by the | ||
| health maintenance organization. | ||
| (b) A health maintenance organization may not use | ||
| extrapolation to complete an audit of a participating physician or | ||
| provider. Any additional payment due a participating physician or | ||
| provider or any refund due the health maintenance organization must | ||
| be based on the actual overpayment or underpayment and may not be | ||
| based on an extrapolation. | ||
| SECTION 3. Subchapter B, Chapter 1301, Insurance Code, is | ||
| amended by adding Section 1301.0642 to read as follows: | ||
| Sec. 1301.0642. USE OF EXTRAPOLATION PROHIBITED. (a) In | ||
| this section, "extrapolation" means a mathematical process or | ||
| technique used by an insurer in the audit of a preferred or | ||
| nonpreferred provider to estimate audit results or findings for a | ||
| larger batch or group of claims not reviewed by the insurer. | ||
| (b) An insurer may not use extrapolation to complete an | ||
| audit of a preferred or nonpreferred provider. Any additional | ||
| payment due a preferred or nonpreferred provider or any refund due | ||
| the insurer must be based on the actual overpayment or underpayment | ||
| and may not be based on an extrapolation. | ||
| (c) If a payment for which a patient has signed an agreement | ||
| to pay is due a preferred or nonpreferred provider, the patient is | ||
| considered to have assumed full financial responsibility for the | ||
| payment, and the payment may not be used as a basis for a claim of | ||
| nonpayment against the insurer. | ||
| SECTION 4. The change in law made by this Act applies only | ||
| to the audit of a physician or provider under a contract with an | ||
| insurer or health maintenance organization entered into or renewed | ||
| on or after the effective date of this Act. | ||
| SECTION 5. This Act takes effect September 1, 2019. | ||
