Bill Text: TX HB1649 | 2017-2018 | 85th Legislature | Engrossed


Bill Title: Relating to the use of extrapolation by a health maintenance organization or an insurer to audit claims.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Engrossed - Dead) 2017-05-18 - Referred to Business & Commerce [HB1649 Detail]

Download: Texas-2017-HB1649-Engrossed.html
  85R21751 MEW-D
 
  By: Muñoz, Jr. H.B. No. 1649
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  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 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 provider.  Any additional payment due a
  preferred provider or any refund due the insurer must be based on
  the actual overpayment or underpayment and may not be based on an
  extrapolation.
         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, 2017.
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