Office of House Bill AnalysisH.B. 1913
By: Capelo


State law requires a preferred provider organization (PPO) or health
maintenance organization (HMO) to provide due process to a provider through
the use of an advisory panel of physicians selected by the PPO or HMO
before the provider is deselected from the PPO's or HMO's  health plan.
Since the panel's decision is of an advisory nature only, a provider who
brings a case before the panel may still be deselected from the health plan
without good cause.  Providers may seek legal redress if they feel their
deselection from a plan is unwarranted, but may not be able to pursue the
action due to time constraints, cost concerns, and the improbability of
prevailing in the suit. House Bill 1913 strengthens the peer review process
by requiring the process to meet certain federal guidelines regarding good
faith professional review activities if a contributing cause of the
termination of a contract is based on utilization review, quality review,
or any action reported to the National Practitioner Data Bank and
authorizing aggrieved parties to bring an action for failure to follow


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. 


House Bill 1913 amends the Insurance Code to provide that if a contributing
cause of the termination of a provider contract by a preferred provider
organization (PPO) or health maintenance organization (HMO) is based on
quality review, including quality issues involving utilization patterns or
any action reported to the National Practitioner Data Bank, the review
mechanism must be a peer review process that meets federal guidelines for
good faith professional review activities and must be conducted before the
PPO or HMO files any complaint with the Texas State Board of Medical
Examiners (board). The bill provides that a PPO or HMO determination that
is contrary to any recommendation of an advisory review panel must be for
good cause shown. In cases in which there is imminent harm to a patient's
health or an action by a state licensing board or other government agency
that effectively impairs a physician's, practitioner's, or provider's
ability to practice medicine, dentistry, or another profession, or in a
case of fraud or malfeasance, the bill authorizes the PPO or HMO to
immediately suspend the physician or practitioner if the physician's or
practitioner's facility admission privileges have been revoked or suspended
for longer than 30 days because of quality of care issues or the physician
or provider is subject to an order of the board that revokes, suspends, or
restricts the physician's or provider's license, if the review process is
initiated simultaneously with the termination or suspension of a contract.