Bill Text: TX HB3124 | 2017-2018 | 85th Legislature | Comm Sub


Bill Title: Relating to certain physician-specific comparison data compiled by a health benefit plan issuer, including the release of that data to physicians participating in certain physician-led organizations.

Spectrum: Partisan Bill (Republican 2-0)

Status: (Engrossed - Dead) 2017-05-26 - Returned to the Senate for further action [HB3124 Detail]

Download: Texas-2017-HB3124-Comm_Sub.html
 
 
  By: Gooden (Senate Sponsor - Creighton) H.B. No. 3124
         (In the Senate - Received from the House May 8, 2017;
  May 9, 2017, read first time and referred to Committee on Business &
  Commerce; May 17, 2017, reported favorably by the following vote:  
  Yeas 8, Nays 0; May 17, 2017, sent to printer.)
Click here to see the committee vote
 
 
A BILL TO BE ENTITLED
 
AN ACT
 
  relating to certain physician-specific comparison data compiled by
  a health benefit plan issuer, including the release of that data to
  physicians participating in certain physician-led organizations.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  The heading to Chapter 1460, Insurance Code, is
  amended to read as follows:
  CHAPTER 1460. [STANDARDS REQUIRED REGARDING] CERTAIN PHYSICIAN
  RANKINGS AND COST COMPARISONS BY HEALTH BENEFIT PLANS
         SECTION 2.  Chapter 1460, Insurance Code, is amended by
  designating Sections 1460.001 and 1460.002 as Subchapter A and
  adding a subchapter heading to read as follows:
  SUBCHAPTER A.  GENERAL PROVISIONS
         SECTION 3.  Section 1460.001, Insurance Code, is amended to
  read as follows:
         Sec. 1460.001.  DEFINITIONS. In this chapter:
               (1)  "Accountable care organization" means an entity:
                     (A)  that is composed of physicians or physicians
  and other health care providers;
                     (B)  that is owned and controlled by one or more
  physicians licensed in this state and engaged in active clinical
  practice in this state;
                     (C)  that contracts with a health benefit plan
  issuer to provide medical or health care services to a defined
  population;
                     (D)  that uses a payment structure that takes into
  account the total costs and quality of the care provided to the
  defined population served by the entity; and
                     (E)  through which physicians and health care
  providers, if any:
                           (i)  share in savings created by improvement
  of the quality of, and reduction of cost increases for, care
  delivered to the defined population served by the entity; or
                           (ii)  are compensated through another
  payment methodology intended to reduce the total cost of care
  delivered to the defined population served by the entity.
               (2)  "Cost comparison data" means information compiled
  by a health benefit plan issuer to show the health care costs
  associated with a physician or other health care provider relative
  to another physician or health care provider.
               (3)  "Designated entity" means a limited liability
  company in which a majority ownership interest is held by an
  incorporated association whose purpose includes uniting in one
  organization all physicians licensed to practice medicine in this
  state and that has been in continued existence for at least 15
  years.
               (4)  "Health benefit plan issuer" means an entity
  authorized under this code or another insurance law of this state
  that provides health insurance or health benefits in this state,
  including:
                     (A)  an insurance company;
                     (B)  a group hospital service corporation
  operating under Chapter 842;
                     (C)  a health maintenance organization operating
  under Chapter 843; and
                     (D)  a stipulated premium company operating under
  Chapter 884.
               (5)  "Participating physician" means a physician who
  participates in an accountable care organization.
               (6) [(2)]  "Physician" means an individual licensed to
  practice medicine in this state or another state of the United
  States.
         SECTION 4.  Chapter 1460, Insurance Code, is amended by
  designating Sections 1460.003 through 1460.007 as Subchapter B and
  adding a subchapter heading to read as follows:
  SUBCHAPTER B.  PHYSICIAN RANKINGS
         SECTION 5.  Section 1460.003(a), Insurance Code, is amended
  to read as follows:
         (a)  Except as provided by Subchapter C, a [A]  health
  benefit plan issuer, including a subsidiary or affiliate, may not
  rank physicians, classify physicians into tiers based on
  performance, or publish physician-specific information that
  includes rankings, tiers, ratings, or other comparisons of a
  physician's performance against standards, measures, or other
  physicians, unless:
               (1)  the standards used by the health benefit plan
  issuer conform to nationally recognized standards and guidelines as
  required by rules adopted under Section 1460.005;
               (2)  the standards and measurements to be used by the
  health benefit plan issuer are disclosed to each affected physician
  before any evaluation period used by the health benefit plan
  issuer; and
               (3)  each affected physician is afforded, before any
  publication or other public dissemination, an opportunity to
  dispute the ranking or classification through a process that, at a
  minimum, includes due process protections that conform to the
  following protections:
                     (A)  the health benefit plan issuer provides at
  least 45 days' written notice to the physician of the proposed
  rating, ranking, tiering, or comparison, including the
  methodologies, data, and all other information utilized by the
  health benefit plan issuer in its rating, tiering, ranking, or
  comparison decision;
                     (B)  in addition to any written fair
  reconsideration process, the health benefit plan issuer, upon a
  request for review that is made within 30 days of receiving the
  notice under Paragraph (A), provides a fair reconsideration
  proceeding, at the physician's option:
                           (i)  by teleconference, at an agreed upon
  time; or
                           (ii)  in person, at an agreed upon time or
  between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
                     (C)  the physician has the right to provide
  information at a requested fair reconsideration proceeding for
  determination by a decision-maker, have a representative
  participate in the fair reconsideration proceeding, and submit a
  written statement at the conclusion of the fair reconsideration
  proceeding; and
                     (D)  the health benefit plan issuer provides a
  written communication of the outcome of a fair reconsideration
  proceeding prior to any publication or dissemination of the rating,
  ranking, tiering, or comparison.  The written communication must
  include the specific reasons for the final decision.
         SECTION 6.  Section 1460.005(a), Insurance Code, is amended
  to read as follows:
         (a)  The commissioner shall adopt rules as necessary to
  implement this subchapter [chapter].
         SECTION 7.  Sections 1460.006 and 1460.007, Insurance Code,
  are amended to read as follows:
         Sec. 1460.006.  DUTIES OF HEALTH BENEFIT PLAN ISSUER. A
  health benefit plan issuer shall ensure that:
               (1)  physicians currently in clinical practice are
  actively involved in the development of the standards used under
  this subchapter [chapter]; and
               (2)  the measures and methodology used in the
  comparison programs described by Section 1460.003 are transparent
  and valid.
         Sec. 1460.007.  SANCTIONS; DISCIPLINARY ACTIONS. (a) A
  health benefit plan issuer that violates this subchapter [chapter]
  or a rule adopted under this subchapter [chapter] is subject to
  sanctions and disciplinary actions under Chapters 82 and 84.
         (b)  A violation of this subchapter [chapter] by a physician
  constitutes grounds for disciplinary action by the Texas Medical
  Board, including imposition of an administrative penalty.
         SECTION 8.  Chapter 1460, Insurance Code, is amended by
  adding Subchapter C to read as follows:
  SUBCHAPTER C.  COST COMPARISON DATA
         Sec. 1460.051.  PROVISION OF COST COMPARISON DATA
  AUTHORIZED. Notwithstanding Section 1460.003, a health benefit
  plan issuer may provide cost comparison data to a participating
  physician or a designated entity.
         Sec. 1460.052.  PROVISION OF CERTAIN COST COMPARISON DATA
  REQUIRED. If cost comparison data associated with health care
  providers other than physicians is available to a health benefit
  plan issuer that provides cost comparison data under Section
  1460.051, the plan issuer shall provide the cost comparison data
  associated with the other health care providers.
         Sec. 1460.053.  REQUIRED DISCLOSURES. Not later than the
  15th business day after the date that a health benefit plan issuer
  receives a request from a participating physician, the health
  benefit plan issuer shall disclose to the physician:
               (1)  the cost comparison data associated with the
  physician;
               (2)  the measures and methodology used to compare
  costs; and
               (3)  any other information considered in making the
  cost comparison.
         Sec. 1460.054.  RIGHT TO DISPUTE. (a)  A health benefit plan
  issuer shall give a physician, regardless of whether the physician
  is a participating physician, a fair opportunity to dispute the
  cost comparison data associated with the physician at least once
  each calendar quarter and when the health benefit plan issuer
  changes the measures and methodology described by Section 1460.053.
         (b)  A physician may initiate a dispute by sending to the
  health benefit plan issuer a written statement of the dispute.
         Sec. 1460.055.  DISPUTE PROCEEDING. (a)  Not later than the
  15th business day after the date a health benefit plan issuer
  receives a statement of the dispute under Section 1460.054, the
  plan issuer shall provide the cost comparison data associated with
  the physician, the measures and methodology used to compare costs,
  and any other information considered in making the cost comparison,
  unless the information was already provided under Section 1460.052.
         (b)  In addition to any written fair reconsideration
  process, the health benefit plan issuer shall provide a cost
  comparison data dispute proceeding, at the physician's option:
               (1)  by teleconference, at an agreed upon time; or
               (2)  in person, at an agreed upon time.
         (c)  At the proceeding described by Subsection (b), the
  physician has the right to:
               (1)  provide information to a decision-maker;
               (2)  have a representative participate in the
  proceeding; and
               (3)  submit a written statement at the conclusion of
  the proceeding.
         (d)  The health benefit plan issuer shall provide to the
  physician who initiated the dispute process under Section 1460.054
  a written communication of the outcome of the proceeding not later
  than the 60th day after the date the physician initiated the dispute
  process.  The written communication must include the specific
  reasons for the final decision.
         Sec. 1460.056.  CORRECTIONS REQUIRED. If in a dispute
  process initiated under Section 1460.054 the health benefit plan
  issuer determines that the physician's cost comparison data is
  inaccurate or the measures and methodology used to compare costs
  are invalid, the health benefit plan issuer shall promptly correct
  the data or update the measures and methodology and associated
  data, as applicable.
         Sec. 1460.057.  MEASURES AND METHODOLOGY. The measures and
  methodology used to compare costs under this subchapter must use
  risk and severity adjustments to account for health status
  differences among different patient populations.
         Sec. 1460.058.  NOTICE REQUIRED. A health benefit plan
  issuer shall provide written notice to a physician who contracts
  with the plan issuer that:
               (1)  explains the plan issuer's compilation and use of
  cost comparison data, the purpose and scope of the plan issuer's
  release of cost comparison data under this subchapter, and the
  requirements of this subchapter regarding cost comparison data; and
               (2)  informs the physician of the physician's rights
  and duties under this subchapter.
         Sec. 1460.059.  CONFIDENTIALITY. A physician who receives
  cost comparison data about another physician under this subchapter
  may not disclose the data to any other person, except for the
  purpose of:
               (1)  managing an accountable care organization;
               (2)  managing the receiving physician's practice or
  referrals;
               (3)  evaluating or disputing the cost comparison data
  associated with the receiving physician;
               (4)  obtaining professional advice related to a legal
  claim; or
               (5)  reporting, complaining, or responding to a
  governmental agency.
         Sec. 1460.060.  CONSTRUCTION OF SUBCHAPTER. Nothing in this
  subchapter may be construed to authorize:
               (1)  the disclosure of a contract rate; or
               (2)  the publication of cost comparison data to a
  person other than a participating physician or a designated
  entity.
         Sec. 1460.061.  RULES. The commissioner shall adopt rules
  as necessary to implement this subchapter.
         Sec. 1460.062.  DUTIES OF HEALTH BENEFIT PLAN ISSUER. A
  health benefit plan issuer shall ensure that:
               (1)  physicians currently in clinical practice are
  actively involved in the development of the standards used under
  this subchapter; and
               (2)  the measures and methodology used in the
  development of cost comparison data described by this subchapter
  are transparent and valid.
         Sec. 1460.063.  SANCTIONS; DISCIPLINARY ACTIONS. (a) A
  health benefit plan issuer that violates this subchapter or a rule
  adopted under this subchapter is subject to sanctions and
  disciplinary actions under Chapters 82 and 84.
         (b)  A violation of this subchapter by a physician
  constitutes grounds for disciplinary action by the Texas Medical
  Board, including imposition of an administrative penalty.
         SECTION 9.  The change in law made by this Act applies only
  to a contract between a physician and a health benefit plan issuer
  entered into or renewed on or after September 1, 2017. A contract
  between a physician and health benefit plan issuer entered into or
  renewed before September 1, 2017, is governed by the law as it
  existed immediately before that date, and that law is continued in
  effect for that purpose.
         SECTION 10.  This Act takes effect September 1, 2017.
 
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