HBA-DMH H.B. 1562 77(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 1562 By: Thompson Insurance 8/3/2001 Enrolled BACKGROUND AND PURPOSE Health care fraud and abuse are costing the national health care system several billion dollars annually. Many losses occur in Medicare and Medicaid programs, but private sector health benefit programs are also affected by fraud. One of the more common methods of health care fraud is to bill for services not performed or to bill for more expensive services than were actually provided. House Bill 1562 sets forth requirements for the investigation of insurance fraud and the business of insurance. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority is expressly delegated to the Texas Workers' Compensation Commission in SECTION 5 (Section 402.084, Labor Code) of this bill. ANALYSIS House Bill 1562 amends the Insurance Code to authorize the insurance fraud unit to receive, review, and investigate in a timely manner insurer antifraud reports. The bill requires the insurance fraud unit to report annually in writing, making the initial report not later than January 1, 2003, to the commissioner of insurance the number of cases completed and any recommendations for new regulatory and statutory responses to the types of fraudulent activities encountered by the insurance fraud unit. The bill requires an insurer who collects direct written premiums to adopt an antifraud plan. The bill authorizes the insurer to annually file the antifraud plan with the insurance fraud unit and specifies what the plan must include. The bill establishes that provisions relating to immunity do not apply to a claim made against a policy issued by a reinsurer. The bill requires an insurers to provide a notice of penalty for false or fraudulent claims on a claim form that is provided to certain claimants. The bill sets forth that certain persons are not subject to liability based on reports or information concerning fraudulent insurance acts if the reports or information are provided to an individual employed by or acting on behalf of an insurer to detect and prevent fraudulent insurance acts. The bill modifies the list of entities to which a person may give information and be exempt from liability. The bill prohibits the information provided by an insurer to the insurance fraud unit or an authorized governmental agency from being subject to public disclosure, but authorizes the information to be used by the insurance fraud unit or governmental agency only for the performance of its duties. The bill provides that an insurer must exercise reasonable care concerning the accuracy of the information conveyed to persons or entities. The bill prohibits information provided by an insurer to an insurance fraud unit or an authorized governmental agency from being subject to public disclosure. The bill authorizes information to be used by the insurance fraud unit or governmental agency only for the performance of its duties. The bill provides that an insurer must exercise reasonable care concerning the accuracy of the information conveyed either to the insurance fraud unit, an authorized governmental agency, other insurers, or other persons or entities. The bill provides that if an insurer participating in the STAR or STAR + Plus Medicaid program or CHIP has in place a fraud and abuse plan approved by a health and human services agency, such a plan meets the requirements of the bill. If an insurer is required by law to report possible fraudulent insurance acts to a health and human services agency and the office of the attorney general, the bill prohibits an insurer from being required to report such acts to the insurance fraud unit. The bill requires the health and human service agencies, the office of the attorney general, and the insurance fraud unit to coordinate enforcement efforts relating to fraudulent insurance acts that occur in relation to the Medicaid program or CHIP. H.B. 1562 amends the Labor Code to authorize the Texas Workers' Compensation Commission (TWCC) to establish by rule a reasonable fee for all information requested to control insurance fraud in an electronic data format by subclaimants or authorized representatives of subclaimants. The bill requires TWCC to adopt rules for public participation to establish reasonable security parameters for all transfers of information requested in electronic data format and to establish requirements regarding the maintenance of electronic data in the possession of a subclaimant or the subclaimant's representative. Information on a claim relating to a subclaimant may include information, in an electronic data format, on all workers' compensation claims necessary to determine if a subclaim exists. The information on a claim remains subject to confidentiality requirements while in the possession of a subclaimant or representative. H.B. 1562 amends the Occupations Code to specify the activities that constitute unprofessional conduct by a health care provider, and provides that, in addition to other provisions of civil or criminal law, such acts of unprofessional conduct constitute cause for the revocation or suspension of a provider's license, permit, registration, certificate, or other authority or other disciplinary action. EFFECTIVE DATE September 1, 2001.