HBA-ALS C.S.H.B. 2883 76(R)BILL ANALYSIS Office of House Bill AnalysisC.S.H.B. 2883 By: Bailey Insurance 4/16/1999 Committee Report (Substituted) BACKGROUND AND PURPOSE C.S.H.B. 2883 provides that a preferred provider contract between an insurer and a licensed podiatrist and a contract between a health maintenance organization and a licensed podiatrist must: authorize the podiatrist to request, and require the insurer to provide within 30 days of the request, a copy of the coding guidelines (guidelines) and payment schedules (schedules) applicable to the compensation that the podiatrist will receive under the contract for services; prohibit the insurer from unilaterally making material retroactive revisions to the guidelines and schedules; and authorize the podiatrist to furnish x-rays and non-prefabricated orthotics covered by the evidence of coverage. 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 3, Article 3.70-3C, Insurance Code, as added by Chapter 1024, Acts of the 75th Legislature, Regular Session, 1997, by adding Subsection (n), as follows: (n) Provides that a preferred provider contract between an insurer and a licensed podiatrist must: _authorize the podiatrist to request, and require the insurer to provide within 30 days of the request, a copy of the coding guidelines (guidelines) and payment schedules (schedules) applicable to the compensation that the podiatrist will receive under the contract for services; _prohibit the insurer from unilaterally making material retroactive revisions to the guidelines and schedules; and _authorize the podiatrist to furnish x-rays and non-prefabricated orthotics covered by the evidence of coverage. SECTION 2. Amends Section 18A, Texas Health Maintenance Organization Act (Article 20A.18A, Vernon's Texas Insurance Code), as added by Chapter 1026, Acts of the 75th Legislature, Regular Session, 1997, by adding Subsection (j), as follows: (j) Provides that a contract between a health maintenance organization (HMO) and a licensed podiatrist must: _authorize the podiatrist to request, and require the insurer to provide within 30 days of the request, a copy of the guidelines and schedules applicable to the compensation that the podiatrist will receive under the contract for services; _prohibit the insurer from unilaterally making material retroactive revisions to the guidelines and schedules; and _authorize the podiatrist to furnish x-rays and non-prefabricated orthotics covered by the evidence of coverage. SECTION 3.Effective date: September 1, 1999. Makes application of this Act prospective. SECTION 4.Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE C.S.H.B. 2883 modifies the original bill in SECTIONS 1 (proposed Section 3(n), Article 3.70-3C, Insurance Code) and 2 (proposed Section 18A(j), Article 20A, Insurance Code) by deleting the text of these two sections that relates to provisions that are mandatory in a contract between an HMO and a physician or provider and a preferred provider contract. Under these two deleted Sections, both a contract between an HMO and a physician or provider, and a preferred provider contract, must: _include a complete fee schedule, all applicable treatment codes, and a complete explanation of the method for determining payment of a physician or provider or preferred provider; _prohibit the HMO or insurer from changing the fee schedule for a physician or provider or preferred provider, respectively, without giving the physician or provider or preferred provider, respectively, 90 days' prior written notice by certified mail and allowing the physician or provider or preferred provider, respectively, to terminate the contract before the implementation of the revised fee schedule without penalty; _prohibit unilateral amendments to the contract, except as authorized above; _prohibit the HMO or insurer from assigning the contract to another entity and causing the physician or provider or provider, respectively, to become a physician or provider or provider, respectively, in another health care plan without the physician's or provider's or provider's, respectively, prior consent; _give the physician or provider or preferred provider, respectively, at least 90 days after the date of service to submit a claim for payment; _require the HMO or insurer to pay a properly submitted and complete claim for payment by a physician or provider or preferred provider, respectively, no later than a specified date, if the HMO or insurer fails to pay a claim as required under this subdivision, require the HMO or insurer to forfeit any applicable fee discount and to instead pay the physician's or provider's or preferred provider's, respectively, usual and customary fee for the service for which the claim was made; _clearly describe all information that must be included on a claim form submitted by a physician or provider or preferred provider to render the claim full and complete for payment purposes; _provide that once eligibility and benefits have been properly verified by the physician or provider or preferred provider, the HMO or insurer, respectively, may not deny a claim for payment on the ground that the enrollee is no longer eligible for coverage or that the benefits have changed; _define "medical necessity" as "the standard for health care services as determined by physicians and providers in accordance with the prevailing practices and standards of the medical profession and the community" and allow a physician or provider or preferred provider to appeal an adverse decision regarding medical necessity to a panel of physicians or providers of the same specialty; _clearly explain the HMO's or insurer's policy regarding global periods and payment methods for multiple surgical procedures that are performed during the same operation; _prohibit the HMO or insurer from denying or interfering with the physician's or provider's or preferred provider's, respectively, right to render medical services and furnish durable medical equipment to patients in the office setting as is customary for physicians or providers or preferred provider of the same medical specialty; _provide for the automatic annual renewal of the contract, unless a party to the contract gives 90 days' prior written notice of termination to the other party stating the reason for the termination; and _provide for all unresolved disputes between the HMO and a physician or provider or an insurer and a preferred provider to be resolved through binding arbitration on the request of either party. Under the substitute, the body of the text for SECTIONS 1 (proposed Section 3(n), Article 3.70-3C, Insurance Code) and 2 (proposed Section 18A(j), Article 20A, Insurance Code) relates to contracts between podiatrists and health care plans. A preferred provider contract between an insurer and a licensed podiatrist and between an HMO and a licensed podiatrist must: _authorize the podiatrist to request, and require the insurer to provide within 30 days of the request, a copy of the coding guidelines (guidelines) and payment schedules (schedules) applicable to the compensation that the podiatrist will receive under the contract for services; _prohibit the insurer from unilaterally making material retroactive revisions to the guidelines and schedules; and _authorize the podiatrist to furnish x-rays and non-prefabricated orthotics covered by the evidence of coverage. C.S.H.B. 2883 modifies the original bill in SECTION 3 by providing that the Act applies only to a contract between an insurer or health maintenance organization and a podiatrist, rather than to a preferred provider contract or a contract between a health maintenance organization and a physician or provider, entered into on or after the effective date of the Act.