Batch Rejection of Clean Claims |
Employer Payment of Health Plan Premiums |
Electronic Transmission of Health Benefit
Information |
Floor for PPO Out-of-Network Benefits | Mandatory Insurance Fraud Reporting
| Managed Care Near Misses | Managed Care Close Calls
Batch Rejection of Clean Claims
SB 50 by Sen. Jane Nelson (R-Lewisville) and Rep. John
Smithee (R-Amarillo) requires health plans to include a contract
provision, upon a physician's request, requiring them to pay
a clean electronic claim consistent with Texas Prompt Pay even if
the clean claim is contained in an electronic batch of claims that
is rejected in its entirety. However, since the end of the regular
legislative session, the Texas Department of Insurance (TDI) has
clarified that the requirement to process an electronic clean claim
exists when the carrier receives it, and that the health plan's
duty to process a clean claim does not depend on a provision in its
contract with a physician. TMA supported this bill.
Employer Payment of Health Plan Premiums
SB 51 by Senator Nelson and Representative Smithee effectively
removes the 30-day grace period that employers have for paying
health insurance premiums for their employees. TMA supported the
bill, which requires employers to be responsible for a health
insurance premium until the end of the month in which an employee
is removed from coverage under a group health plan. The bill states
that the insurer isto be notified of such removal to prevent
retroactive recovery of payments made to physicians for medical
services provided in good faith prior to retroactive termination of
the employee's health plan coverage. SB 51 also changes
verification and preauthorization call center requirements for
dental and vision HMOs.
Electronic Transmission of Health Benefit Information
SB 1149 by Sen. Chris Harris (R-Arlington) and Rep. Craig Eiland
(D-Galveston) requires health plans to make available to a
physician or other provider at the time of the patient's visit,
either telephonically or electronically, certain patient-specific
information including enrollment and eligibility status, benefits,
and financial responsibility. TMA strongly supported this bill. It
is the first in a series of steps to move health plans toward the
use of smart card technology. The Texas Association of Health Plans
(TAHP) testified in favor of this bill when the Senate State
Affairs Committee heard it. However, by the time the bill was heard
by the House Insurance Committee, TAHP had changed its mind and
testified in opposition to the bill.
Floor for PPO Out-of-Network Benefits
HB 1030 by Rep. Larry Taylor (R-Friendswood) and Sen. Mike
Jackson (R-La Porte) amends existing statute to set a floor for PPO
out-of-network benefits at no less than 50 percent. Previously,
informal guidelines used by TDI limited the spread for enrollee
cost-sharing between in-network and out-of-network benefits to 30
percent. This bill allows for a possible difference greater than 30
percent, but enrollees' coinsurance for services provided by
out-of-network physicians may not exceed 50 percent of the amount
covered. TMA testified in the House Insurance Committee opposing
this bill as filed but worked with Representative Taylor to address
concerns. The association subsequently supported the provision
establishing the 50 percent floor.
Mandatory Insurance Fraud Reporting
HB 2388 by Rep. Senfronia Thompson (D-Houston) and Sen. Troy
Fraser (R-Horseshoe Bay) mandates health plan reporting to the TDI
fraud unit within 30 days of determining or suspecting that a
fraudulent act has occurred. TMA supported this bill as a response
to health plan claims that the Texas Prompt Pay requirements
restrict their ability to investigate possible fraudulent health
care claims. This bill will allow TDI to track and report to the
legislature the level of reported fraudulent activity so an
analysis can be made to determine what, if any, adverse impact
Texas Prompt Pay is having on health plan fraud investigations.
Managed Care Near Misses
House Bill 1776 by Representative Debbie Riddle (R-Tomball)
would have explicitly prohibited HMOs and PPOs from discriminating,
limiting, or directing patients within its network through
increasing enrollee cost-shares. TMA strongly supported this bill
as a way to stop health plans' use of tiered networks to limit
patient access to "approved" network physicians as well as reducing
physician reimbursement. The bill died in the House Insurance
Committee.
Managed Care Close Calls
Several bad managed care bills were defeated early in the fight
over inadequate health plan networks. These bills could very easily
reappear in 2007. Below is a brief summary.
Mandatory Electronic Claims Filing
SB 49 by Senator Nelson and Representative Smithee would have
mandated health plan contracts to require physicians and other
providers to submit claims electronically. TMA was successful in
getting this language removed from 2003's prompt pay bill, SB 418.
The bill died in the House Local and Consent Committee.
HMO in Name Only
HB 1570 by Representative Taylor and Sen. Kip Averitt
(R-McGregor) would have allowed standard benefit plans (as passed
by SB 541 in 2003) to use exclusive provider organization networks.
The bill also would have allowed HMO and point-of-service plans to
remove or change time and cost limitations for health care
services, and would have tiered cost shares comparable to PPOs. TMA
viewed this as the worst possible scenario for patients and
physicians by allowing HMOs to become, in essence, closed- network
PPOs with no out-of-network benefits. The association strongly
opposed HB 1570, which died in the Senate State Affairs
Committee.
Prompt Pay Extension
House Bill 3371 by Representative Taylor would have allowed
health plans to apply for an extension of the Texas Prompt Pay
deadlines upon suspicion of provider fraud. The health plan was
required to notify both TDI and the physician or provider. HB 3371
died in the House Insurance Committee.
Managed Care/Insurance TMA Staff Contacts:
- Hilary Dennis, Legislative Affairs, (512) 370-1370
- Teresa Devine, Health Care Financing, (512) 370-1415
- Lee Spangler, JD, Office of the General Counsel, (512)
370-1337
Overview
|
Tax Reform
|
Scope of Practice
|
Physician Ownership
|
Inadequate Health Plan Networks
(Balanced Billing)
|
Texas State Board of Medical
Examiners Sunset and Physician Licensure
|
Agency Sunset Review
|
Corporate Practice of Medicine
|
Health Care Funding
|
Medicaid and CHIP
|
Indigent Care and the
Uninsured
|
Workers' Compensation
|
Professional Liability Reform
|
Medical Education/Workforce
|
Child Health, Safety, and
Nutrition/Fitness
|
Public Health
|
Border Health
|
Rural Health
|
Mental Health
|
Trauma/EMS
|
Prescription Drugs
|
Medical Science
|
Long-Term Care
|
Abortion
|
Transplantation/Organ Donation
|
Table of Contents