HBA-DMD H.B. 2545 76(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 2545 By: Brimer Business & Industry 3/11/1999 Introduced BACKGROUND AND PURPOSE Currently, the criteria used by the Texas Workers' Compensation Commission (commission) when determining whether to approve or deny an injured worker's request for a change of the treating doctor is ambiguous. As a result, the commission routinely allows the first change to be made without detailed scrutiny even though a change of doctors is prohibited by the Workers' Compensation Act if the change is used to circumvent the prohibition against changing doctors for the purpose of securing a new impairment rating or medical report. Currently, an insurance carrier is required to pay the fee for services provided by a health care provider (provider) within 45 days after receiving the charge, unless the insurance carrier disputes the charge, in which case the insurance carrier is required to pay 50 percent of the fee within 45 days after receiving the charge. The commission's fee guidelines have not been reviewed since 1996, although the commission is required to review the guidelines every two years. Also, providers are currently prohibited from pursuing a private claim against a workers' compensation claimant for a health care service provided to the claimant, but a collection agency is not prohibited from doing so. H.B. 2545 requires the commission to determine whether an independent medical consultation would be beneficial when deciding whether changing an employee's doctor is medically necessary and to notify the employee, within 10 days, of the commission's decision pertaining to the change of the employee's doctor. This bill requires the insurance carrier to pay the fee which is charged for a service rendered no later than 20 days after receiving the charge, unless the amount is disputed, in which case the insurance carrier is required to pay 50 percent of the amount within 20 days. It also authorizes the commission to impose additional reimbursement restrictions and preauthorization requirements on a provider and provides that interest accrues on an unpaid fee or charge consistent with the fee guidelines and sets the terms for the fee. Additionally, this bill prohibits a provider or any other person from pursuing a private claim against a workers' compensation claimant for the cost of a health care service provided to the claimant, with exceptions. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that this bill does not expressly delegate any additional rulemaking authority to a state officer, department, agency, or institution. SECTION BY SECTION ANALYSIS SECTION 1. Amends Section 408.022(b), Labor Code, as follows: (b) Authorizes an employee to select an alternate doctor, if the employee is dissatisfied with the initial choice of a doctor from the list approved by the Texas Workers' Compensation Commission (commission), after a written application to and being granted approval by the commission, rather than authorizing the employee to notify the commission and request authority to select an alternate doctor. Provides that the commission must determine that the change is medically warranted before approving the change, unless the insurance carrier agrees to the employee's requested change. Requires the commission to consider whether an independent medical consultation is necessary to evaluate the appropriateness of the treating doctor's diagnosis or treatment, before denying a request for a change in treating doctors. Requires the commission to notify the employee of its decision no later than 10 days after the employee's request is received by the commission. Deletes the provision that the notification must be in writing, except when notification may be by telephone when a medical necessity exists for immediate change. SECTION 2. Amends Section 408.027, Labor Code, by amending Subsections (a) and (b) and adding Subsection (e), as follows: (a) Requires an insurance carrier to pay the fee which is charged for a service rendered by a health care provider (provider) no later than 20, rather than 45, days after the insurance carrier receives the charge unless the amount of the payment or the entitlement to payment is disputed. (b) Requires an insurance carrier, if the insurance carrier disputes the amount charged by a provider and requests an audit of the services rendered, to pay 50 percent of the amount charged by the provider no later than 20, rather than 45, days after the insurance carrier receives the statement of charge. (e) Requires an insurance carrier, notwithstanding Subsections (a) and (b), to pay the fee charged for a service rendered by a provider no later than 31 days after the insurance carrier receives the charge unless the amount of the payment or the entitlement to payment is disputed. SECTION 3. Amends Section 413.012, Labor Code, to require the fees provided in the guideline be increased by three percent each year, if the medical policies and fee guidelines are not received within the required two-year period for review and revision of medical policies and fee guidelines, until the medical policy or fee guideline is revised or repealed. SECTION 4. Amends Section 413.014, Labor Code, by adding Subsections (c), (d), and (e), as follows: (c) Authorizes the commission to impose additional reimbursement restrictions and preauthorization requirements on a provider that does not comply with this title or commission rules after notifying the provider of the noncompliance. (d) Establishes that a person who performs or assists in performing services for the commission has the same immunity from liability that a commission member has under Section 402.010 (Civil Liability of Member), Labor Code. (e) Establishes that an act by the commission under this section does not constitute utilization review and is not subject to Article 21.58A (Health Care Utilization Review Agents), Insurance Code. SECTION 5. Amends Section 413.019, Labor Code, by amending Subsection (a) and adding Subsection (c), as follows: (a) Provides that interest on an unpaid fee or charge that is consistent with the fee guidelines accrues at the rate provided by Section 401.023 (Interest or Discount Rate), Labor Code, beginning on the 20th, rather than 60th, day after the provider submits the bill to an insurance carrier until the date the bill is paid. (c) Provides that, notwithstanding Subsection (a), interest on an unpaid fee or charge that is consistent with the fee guidelines accrues at the rate provided by Section 401.023 beginning on the 30th day after the provider submits the bill to an insurance carrier until the date the bill is paid. Sets forth that this subsection expires September 1, 2001. SECTION 6. Amends Section 413.042(a), Labor Code, as follows: (a) Prohibits a provider or any other person, rather than a provider, from pursuing a private claim against a workers' compensation claimant for all or part of the cost of a health care service provided to the claimant by the provider, with certain exceptions. SECTION 7.Effective date: September 1, 1999. Makes application of SECTIONS 2 and 5 of this Act prospective. SECTION 8.Emergency clause.