HBA-DMH S.B. 1143 77(R)    BILL ANALYSIS


Office of House Bill AnalysisS.B. 1143
By: Carona
Insurance
4/22/2001
Engrossed



BACKGROUND AND PURPOSE 

Currently, all contracts between health maintenance organizations (HMOs)
and physicians or other providers require credentialing. The initial
credentialing process includes an application, verification of information,
and a site visit. Texas has not updated the standards on credentialing HMOs
to stay in compliance with standards promulgated by the National Committee
for Quality Assurance (NCQA). Medicaid and Medicare credentialing standards
are based on NCQA standards. Senate Bill 1143 provides for updating
credentialing standard to stay in compliance with NCQA's standards. 

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. 

ANALYSIS

Senate Bill 1143 amends the Insurance Code to require the commissioner of
insurance (commissioner) to require a health maintenance organization (HMO)
to verify that a physician's license to practice medicine and any other
certificate the physician is required to hold is valid as of the date of
initial credentialing and on the date of each recredentialing.  The bill
requires the commissioner to require an HMO that conducts a site visit for
the purpose of initial credentialing to evaluate during the visit a site's
accessibility, appearance, space, medical or dental recordkeeping
practices, availability of appointments, and confidentiality procedures.
The bill prohibits the commissioner from requiring that an HMO  
 
 _evaluate the appropriateness of equipment during the site visit;
 
_formally recredential physicians or providers more frequently than once in
any three-year period;  

_verify the validity of a license or certificate held by a physician other
than as of the date of initial credentialing or recredentialing of the
physician;  

_use clinical personnel to perform a site visit for initial credentialing
of a physician or provider unless clinical review is needed during the site
visit; or  

_require a site visit be performed for recredentialing of a physician or
provider.  

These provisions do not preclude an HMO from performing a site visit of a
physician or provider at any time for cause.  Rules adopted by the
commissioner for HMO quality assurance that relate to implementation and
maintenance by an HMO of a process for selecting and retaining affiliated
physicians and providers must comply with this bill and standards
promulgated by the National Committee for Quality Assurance, to the extent
those standards do not conflict with other laws of this state.  


 EFFECTIVE DATE

September 1, 2001.