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) 2019-03-26 - Referred to Human Services [HB4572 Detail]

Download: Texas-2019-HB4572-Introduced.html
 
 
  By: Raymond H.B. No. 4572
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  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.
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