Bill Text: TX HB4572 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the establishment of the independent provider health plan monitor for certain appeals in the Medicaid managed care program.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2019-03-26 - Referred to Human Services [HB4572 Detail]
Download: Texas-2019-HB4572-Introduced.html
By: Raymond | H.B. No. 4572 |
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relating to the establishment of the independent provider health | ||
plan monitor for certain appeals in the Medicaid managed care | ||
program. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Chapter 533, Government Code, is amended by | ||
adding Subchapter F to read as follows: | ||
SUBCHAPTER F. INDEPENDENT PROVIDER HEALTH PLAN MONITOR | ||
Sec. 533.301. DEFINITION. In this subchapter, "monitor" | ||
means the person serving as the independent provider health plan | ||
monitor under this subchapter. | ||
Sec. 533.302. ESTABLISHMENT. (a) The commission shall | ||
establish the position of independent provider health plan monitor | ||
within the commission. | ||
(b) The independent provider health plan monitor shall | ||
create an independent review process that utilizes the standards of | ||
the Independent Review Organization process under Section | ||
4202.002, Texas Insurance Code. | ||
Sec. 533.303. REVIEW OF CORRECTIVE ACTIONS. (a) A health | ||
care provider in the managed care organization's provider network | ||
may petition the monitor in the form and manner provided by | ||
commission rule to review a corrective action taken by a managed | ||
care organization that is not agreed to by the provider in | ||
connection with, but not limited to, pre-authorization denials, | ||
reimbursement, standard of care, a claim payment denial, | ||
disagreement about medical or treatment necessity, or compliance | ||
with commission rules and contractual terms. | ||
(b) The monitor shall review a case submitted under | ||
Subsection (a) and issue a decision in accordance with this | ||
subchapter. | ||
Sec. 533.304. PROCEDURES. (a) The monitor shall: | ||
(1) provide written notice of the submission of a | ||
petition under Section 533.303 to the party opposing the party that | ||
submitted the petition; and | ||
(2) allow the opposing party to submit evidence to the | ||
monitor not later than the: | ||
(A) 10th day after the monitor provided the | ||
notice for petitions involving pre-authorizations, or medical or | ||
treatment necessity denials, or | ||
(B) 30th day after the date the monitor provided | ||
the notice for all other petitions. | ||
(b) Not later than the 30th day after the deadline for the | ||
submission of evidence under Subsection (a), the monitor shall | ||
provide written notice to the parties of the monitor's decision for | ||
the case. | ||
(c) While the review process or an appeal by either a | ||
provider or the managed care organization is ongoing, the managed | ||
care organization shall not recoup any funds or otherwise penalize | ||
a provider. | ||
(d) In reaching a decision under Subsection (b), the monitor | ||
shall conduct interviews with all relevant parties and review any | ||
submitted documentation and other evidence to determine whether: | ||
(1) the managed care organization complied with: | ||
(A) applicable commission rules; and | ||
(B) the organization's internal policies | ||
and procedures for auditing or taking a corrective action against a | ||
health care provider; and | ||
(2) the health care provider: | ||
(A) complied with applicable commission | ||
rules; | ||
(B) submitted required documentation in | ||
accordance with the law; and | ||
(C) engaged with a recipient. | ||
(e) The decision made by the monitor shall be binding unless | ||
appealed by the provider or the managed care organization. | ||
(f) An adverse decision against a managed care organization | ||
shall be registered as a verified complaint within the commission's | ||
system and shall be subject to any appropriate penalties by the | ||
commission. | ||
(g) An adverse decision against a managed care organization | ||
shall be subject to the prompt payment penalty from the beginning | ||
date of the late payment. | ||
Sec. 533.305. APPEAL. A managed care organization or | ||
health care provider may appeal the monitor's decision under | ||
Section 533.304 to the State Office of Administrative Hearings. | ||
Sec. 533.306. REPORT. The monitor shall compile and | ||
provide an annual report to the commission on: | ||
(1) the number of corrective actions reviewed by the | ||
monitor for which petitions were submitted by a health care | ||
provider; | ||
(2) the number of corrective actions reviewed by the | ||
monitor for which petitions were submitted by a managed care | ||
organization; | ||
(3) the number of corrective actions overturned by the | ||
monitor; | ||
(4) the number of corrective actions upheld by the | ||
monitor; | ||
(5) the reasons for submissions by health care | ||
providers of petitions to the monitor; | ||
(6) the amount of money managed care organizations | ||
recovered in corrective actions upheld by the monitor; and | ||
(7) the amount of money reimbursed to health care | ||
providers through corrective actions overturned by the monitor. | ||
SECTION 2. As soon as practicable after the effective date | ||
of this Act, the executive commissioner of the Health and Human | ||
Services Commission shall adopt rules necessary to implement | ||
Subchapter F, Chapter 533, Government Code, as added by this Act, | ||
and the commission shall establish the position of independent | ||
provider health plan monitor under that subchapter. | ||
SECTION 3. If before implementing any provision of this Act | ||
a state agency determines that a waiver or authorization from a | ||
federal agency is necessary for implementation of that provision, | ||
the agency affected by the provision shall request the waiver or | ||
authorization and may delay implementing that provision until the | ||
waiver or authorization is granted. | ||
SECTION 4. This Act takes effect September 1, 2019. |