Bill Text: TX SB1636 | 2017-2018 | 85th Legislature | Introduced
Bill Title: Relating to the use of extrapolation by a health maintenance organization or an insurer to audit claims.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2017-03-22 - Referred to Business & Commerce [SB1636 Detail]
Download: Texas-2017-SB1636-Introduced.html
| 85R3340 MEW-D | ||
| By: Campbell, Buckingham | S.B. No. 1636 | |
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| relating to the use of extrapolation by a health maintenance | ||
| organization or an insurer to audit claims. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. Section 843.340, Insurance Code, is amended by | ||
| adding Subsections (f) and (g) to read as follows: | ||
| (f) A health maintenance organization may not use | ||
| extrapolation to complete an audit of a participating physician or | ||
| provider. Any additional payment due a participating physician or | ||
| provider or any refund due the health maintenance organization must | ||
| be based on the actual overpayment or underpayment and may not be | ||
| based on an extrapolation. | ||
| (g) In this section, "extrapolation" means a mathematical | ||
| process or technique used by a health maintenance organization in | ||
| the audit of a participating physician or provider to estimate | ||
| audit results or findings for a larger batch or group of claims not | ||
| reviewed by the health maintenance organization. | ||
| SECTION 2. Section 1301.105, Insurance Code, is amended by | ||
| adding Subsections (e) and (f) to read as follows: | ||
| (e) An insurer may not use extrapolation to complete an | ||
| audit of a preferred provider. Any additional payment due a | ||
| preferred provider or any refund due the insurer must be based on | ||
| the actual overpayment or underpayment and may not be based on an | ||
| extrapolation. | ||
| (f) In this section, "extrapolation" means a mathematical | ||
| process or technique used by an insurer in the audit of a preferred | ||
| provider to estimate audit results or findings for a larger batch or | ||
| group of claims not reviewed by the insurer. | ||
| SECTION 3. The change in law made by this Act applies only | ||
| to the audit of a physician or provider under a contract with an | ||
| insurer or health maintenance organization entered into or renewed | ||
| on or after the effective date of this Act. | ||
| SECTION 4. This Act takes effect September 1, 2017. | ||
