Source: http://www.tdi.texas.gov/rules/2002/bundling2.html
Timestamp: 2017-12-15 12:16:06
Document Index: 625544831

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The Commissioner of Insurance adopts amendments to §11.901, concerning required contracting provisions for health maintenance organizations (HMOs). The amendments are adopted with changes to the proposed text as published in the June 14, 2002 issue of the Texas Register (27 TexReg 5071).
The amendments address the disclosure of certain information concerning fee schedules and coding procedures that affect the payment for services provided by physicians and other health care providers pursuant to a physician or provider contract with an HMO that is subject to Texas Insurance Code Art. 20A.18B. The amendments implement Art. 20A.18B(i), which states that HMOs shall provide contracting physicians and providers with copies of all applicable claim processing policies or procedures. The amendments clarify that an HMO must disclose information concerning fees and coding that affects the payment to be made to a physician or provider for services that the physician or provider has contracted to provide on behalf of an HMO. Lack of contractual access to this information may have prevented some physicians or providers from ascertaining whether they had been compensated according to the terms of their contracts with HMOs. The adopted amendments are designed to address this situation.
The department´s proposed rule contained two alternatives, each intended independently to accomplish the stated purpose. Alternative one was contained at §11.901(10) and alternative two was contained at §11.901(11) of the proposed rule. After receiving comments, the department has decided to adopt alternative one, with changes from the proposed version. In response to comments and for clarification, the department has changed §11.901(7), (8), (9), (10), (10)(A), (10)(A)(i)(I) and (II), (ii), (iv), (B), (B)(i) - (iii), (D), (F), (G)(i) and (ii). None of the changes introduce a new subject matter or affect additional persons other than those subject to the proposed rule as originally published.
The amendments to §11.901(7) require that a contract between a physician or provider and an HMO contain terms regarding compliance with all applicable prompt pay statutes and regulations. The adopted alternative, new paragraph (10) to §11.901, requires that upon request from a physician or provider, an HMO must provide physician- or provider-specific information in a level of detail so that a reasonable person with sufficient training, experience and competence in claims processing (skilled reasonable person) can determine the payment to be made according to the terms of the contract. The request may be provided by any reasonable and verifiable means, such as e-mail or facsimile. The information the HMO must provide must include a physician- or provider-specific summary and explanation of all methodologies that will be used to pay claims submitted in accordance with the contract, including a fee schedule, any applicable coding methodologies, bundling processes, downcoding policies, and any other applicable policy or procedure used by the HMO in paying claims for covered services under the contract. The information provided includes physician-specific and provider-specific fee schedules that pertain to the range of health care services reasonably expected to be provided under the contract by that contracting physician or provider. Additionally, the HMO must provide any addendum, schedule, exhibit or policy necessary to provide a reasonable understanding of the information that is being disclosed to the physician or provider. For example, a fee schedule that indicates that the HMO will reimburse certain claims at a usual and customary rate must explain how the HMO will determine the usual and customary rate for a particular service. An HMO may provide any required information using any reasonable method that is accessible by the physician or provider, including e-mail, computer disks, paper or access to an electronic database. If information is held by an outside source and is not within the control of the HMO, such as state Medicaid or federal Medicare fee schedules, the HMO must explain the procedure by which the physician or provider may access the outside source. An HMO that cannot provide any information required by §11.901(10) due to copyright laws or a licensing agreement may supply a summary of the required information. However, the summary must be sufficient to allow the physician or provider to determine the payment to be made under the contract. Any claims payment information required to be provided pursuant to this paragraph may be amended, revised or substituted only upon written notice to the physician or provider at least 60 calendar days prior to the effective date of the amendment, revision or substitution. The requirements added by paragraph (10) apply to all HMOs as of the effective date of these amendments. Upon receipt of a request, the HMO must provide the information by the later of the 90th day after the effective date of the rule or the 30th day after the HMO receives the request. However, for contracts entered into or renewed on or after the effective date of these amendments, the HMO must provide the required information upon request contemporaneously with other contractual materials. Some HMOs commented that they already have procedures established and are currently delivering this information to their physicians and providers. The department acknowledges that fact and expects that the rule´s establishment of a timeframe for HMOs that have not yet implemented such procedures will not interrupt this practice.
A physician or provider receiving information pursuant to paragraph (10) may not use or disclose the information for any purpose other than practice management or billing activities. A physician or provider may not use the information to misrepresent the level of services actually performed when submitting a claim under the contract. Information provided pursuant to these amendments about a particular service does not constitute a verification that the service a physician or provider has provided or proposes to provide is a covered benefit for a particular enrollee. Paragraph (10) is not intended to dictate the types of practices, policies or procedures that relate to or affect the claims payment process an HMO may elect to employ. In addition, other plan requirements, including co-payments, co-insurance, or deductibles may also affect the actual amount of reimbursement.
Where applicable, the department has indicated comments received on the comparable Chapter 3 rule, §3.3703, published elsewhere in this issue of the Texas Register, by enclosing the reference in brackets.
Agency Response: The department appreciates the commenters´ input on the alternatives. The department recognizes that there are questions concerning the sufficiency of information that carriers are currently providing to physicians and providers. As previously noted, the commissioner has adopted alternative one with changes as a reasonable compromise which preserves the rule´s intent yet addresses the commenters´ concerns.
Agency Response: The department believes that the requirements of Art. 20A.18B make the addition of the suggested language unnecessary. The department will continue to monitor this issue to determine if future rulemaking is warranted.
Costs: Some commenters contend that alternative one places an unnecessary and costly burden on carriers to provide information that would have little distinguishable benefit to physicians and providers. These commenters believe that the proposed rule's cost estimates have been underestimated and that the rule will have a detrimental impact on carriers, driving up the costs of health care premiums and adversely affecting the prompt payment of clean claims. Another commenter contends that the costs of complying with alternative one are at least double the costs of complying with alternative two, due to the requirement that carriers mail hundreds of thousands of codes to thousands of physicians. Some commenters note that this mass mailing will result in some physicians and providers receiving inapplicable codes and other information, as well as burdensome documentation. A commenter contends that tailoring the package to individual providers would have a high price tag as well. The commenter claims that the anticipated cost burden from alternative one would include substantial overhaul of health plan contracts, provision of massive amounts of potentially irrelevant information to providers, review of information to assure compliance with the reasonable claims reviewer standard, revision of existing contracts within the 90-day timeframe, and provision of the 60-day notice of changes to the fee and claims review information. A commenter is concerned that alternative one is too prescriptive, and will increase administrative costs and interfere with updating and improvement of the claims payment system. Other commenters believe that the proposal will give providers a competitive advantage in health plan negotiations, and will make information widely available that will gradually erode provider discounts.
Some commenters note that this provision presupposes that a physician or provider is having claims payment issues with all the carriers with which it contracts, which has not been the commenters´ experience. The commenters believe it would be punitive to require all carriers to provide the amount of information set forth in the rule when some physicians and providers are satisfied with their relationship with some carriers.
The commenters contend that the second alternative will be less costly and burdensome to administer because it requires the disclosure of the information at the request of the provider. The commenters believe this will enable the carriers to provide information more tailored to the physician´s or provider's practice area.
Agency Response: The department appreciates the commenters´ concerns regarding the cost and difficulty of implementation. The department does not intend the rule to place an undue burden on carriers or to inundate physicians and providers with unnecessary information. Rather, it is the department's intent that physicians and providers receive sufficient information so that a skilled reasonable person can determine the payment to be made in accordance with the contract. The department believes that the rule as adopted ­ which allows the information to be distributed electronically or by other means and upon request ­ is a reasonable compromise which preserves the rule´s intent yet addresses the commenters´ concerns. Regarding any potentially burdensome overhaul of contracts, the department has modified alternative one so that the required information itself is not set out at length in the contract. The department understands that implementation of the statute will likely result in physicians and providers receiving more information during the contracting process than they currently do; however, the statute requires full disclosure of a carrier´s claims payment policies and procedures. The department also believes that some of the comments were based on the incorrect assumption that carriers must provide a comprehensive set of claims processing materials to every contracting physician or provider rather than provider- or specialty-specific materials, as the rule states.
Internet Availability of Information: Some commenters suggest that carriers be permitted to comply with the requirement through an administrative guide, electronic-based communication, or upon request from the physician or provider. The commenters also suggest that the carrier have the option to provide the information in the most cost effective manner. A few commenters suggest allowing the information to be accessed through the Internet by contracted providers utilizing a protected password. The commenters believe that this will reduce costs for the health plan and allow a certain level of security for what is considered proprietary information. Another commenter questions the efficacy of web security to protect confidential information.
§11.901(10)(B)(iv) & (D) [§3.3703(a)(20)(B)(iv) & (D)]: A commenter requests clarification that the proposal does not require existing contracts with physicians or providers to be rewritten. Another commenter recommends deletion of these clauses as burdensome and expensive because they would require a contract amendment every time an internal manual, memo or document is updated. A commenter objects to subparagraph (D) as being too broad, having a significant cost impact, and impeding quality improvement in claims processing systems. A commenter does not believe that the contract should be the main source for reimbursement policy information. The commenter explains that most of its contracts are evergreen, subject to termination notification requirements by either party. The commenter recommends that carriers be permitted the flexibility to adapt, improve and update their administrative processes without requiring amendment of contracts to accommodate internal changes. Some commenters believe that the rule should not pertain to routine process changes but should require notice to physicians and providers of updates to schedules and claims payment software.
Agency Response: The department agrees and has modified alternative one so that the required information itself is not set out at length in the contract. Thus, an existing contract does not need to be rewritten but the required information must be provided to the physician or provider upon request. However, all new or renewed contracts must include the requirements of paragraph (10). The department believes making such materials available electronically will minimize the cost of informing physicians and providers of changes. The department notes that the basic requirement of the rule is to ensure that physicians and providers have sufficient information to determine the payment to be made in accordance with the contract, and this criterion should be used to determine when the 60-day notice is required.
§11.901(10) [§3.3703(a)(20)]: A commenter asserts that providing the voluminous information required by the proposal will slow down the negotiation of contracts, both during the 90-day compliance period and at renewal time each year, which could cause a serious disruption in services.
Agency Response: The department understands that implementation of the statute will likely result in physicians and providers receiving more information during the contracting process than they currently do. However, the statute requires full disclosure of a carrier´s claims payment policies and procedures. The department believes that the rule as adopted ­ which allows the information to be distributed electronically and upon request ­ is a reasonable compromise which preserves the statute´s intent yet addresses the commenters´ concerns. A request may be provided by any reasonable and verifiable means, such as e-mail or facsimile. The department expects that parties will negotiate in good faith and on a schedule designed to avoid a disruption of services.
Agency Response: The department appreciates the commenter´s concern that some aspects of the rule may affect some physicians and providers differently than others. The purpose of the rule, however, is simply to assure the delivery of sufficient information for a skilled reasonable person to make a determination of the payment to be made under a contract, regardless of the particular fee schedule or billing practice.
§11.901(11) [§3.3703(a)(20)]: Some commenters support alternative two with changes. The commenters recommend a more balanced approach to disclosure that would also require physicians and providers to disclose to carriers a list of their billed charges for treatment and services. The commenters believe that a dual disclosure process is necessary to maintain a balanced negotiation process that is not unduly weighted in favor of one party. The commenters also believe that this approach will be beneficial to consumers.
Agency Response: The department recognizes this concern, but notes that it has limited authority over physicians and providers and suggests that carriers address this issue in their contract negotiations.
§11.901(10)(B) & (C) [§3.3703(a)(20)(B) & (C)]: A commenter recommends adding references to utilization review (UR) criteria because these criteria are used to determine both medical necessity and the level of reimbursement to be paid.
Agency Response: The department declines to make this change as Art. 20A.18B requires only the disclosure of UR policies. However, Insurance Code Art. 21.58A stipulates that providers are entitled to the UR determination of medical necessity for proposed services and sets forth the timetable for notifying the provider of the decision. It further states that the notice of the UR decision must include a description or the source of the screening criteria upon which that decision is based.
§11.901(10)(A) [§3.3703(a)(20)(A)]: A few commenters suggest removing the word "reasonable" before the word "person" because it is redundant in context. Some commenters recommend deleting the word "summary" because the term is inconsistent with the type of detailed information that must be provided.
As to deletion of "summary," the other requirements the rule places on summaries make the term specific and meaningful as a standard for compliance. So long as a carrier ensures that its summary includes sufficient information to meet the skilled reasonable person standard, it will be in compliance. The rule allows carriers flexibility to meet this requirement by utilizing any reasonable method that is accessible by the physician or provider.
§11.901(10)(C) [§3.3703(a)(20)(C)]: A commenter suggests that the rule mandate that health plan contracts require training certification for provider billing staff.
§11.901(10)(A)(i), (i)(II) - (iv) [§3.3703(a)(20)(A)(i), (i)(II) - (iv)]: A commenter recommends that the provisions describing the carrier´s fee schedule be expanded to include certain billing codes or code groupings and per diem and case rate payments and that the services that are excluded from the per diem or case rate amounts be identified.
Some commenters recommend the addition of references to standard coding methodologies, utilization review criteria and policies developed or used by the HMOs, and procedures or revenue code groupings that contribute to the determination of case rates or per diem payments. Some commenters also seek definitions for "bundling," "downcoding," "component codes," "standard coding methodology," "nonstandard coding methodology" and "recoupment," as well as the phrase "global service periods, comprehensive codes, component codes and mutually exclusive procedures." Agency Response: The department disagrees that this is necessary, as the rule makes clear that the carrier has to provide sufficient information so that a person meeting the skilled reasonable person standard can determine the payment to be made under the contract. Although the adopted rule does specify certain methodologies and processes, this is not an exclusive list. "Including" is a term of enlargement and not of limitation or exclusive enumeration. The department has combined subclauses (i) and (ii) to delete reference to "nonstandard." The department does not believe it is necessary to define the remaining terms, as they are widely recognized by the industry.
§11.901(10)(A)(i)(I) [§3.3703(a)(20)(A)(i)(I)]: A commenter recommends inserting the words "to be" before the word "submitted" to clarify that the carrier must disclose all fees related to all possible services the physician or provider may provide. The commenter believes that, as written, this could be interpreted to mean that a carrier must provide only fees associated with codes a physician has previously submitted.
Agency Response: The department disagrees, as it believes that the provisions as written are sufficiently clear to explain that the information to be provided is not limited to only those fees associated with codes a contracting physician or provider has previously submitted. The carrier must provide the fee schedules and applicable codes and modifiers by which all claims for covered services will be calculated. This includes all services contemplated by the contract between the carrier and the physician or provider, regardless of whether claims for any of those services have been previously submitted.
§11.901(10)(A)(i)(II) [§3.3703(a)(20)(A)(i)(II)]: Some commenters suggest replacing the words "may request" with the words "will receive" so that the carrier cannot refuse to provide the fee schedules. A few commenters also suggest adding the phrase "by law" after the word "authorized" to clarify that the law allows for the disclosure of the information as well as clarify that the reference is to any services the physician may legally provide.
Agency Response: With regard to the first comment, the department believes that the adopted rule ensures the physician and provider will receive the information upon request. The department has removed the word "authorized" from the adopted rule and has substituted the language "intends to provide."
§11.901(10)(A)(iii) [§3.3703(a)(20)(A)(iii)]: A few commenters recommend the addition of the words "anesthesia units" after "component codes." One commenter seeks to include reference to "frequency parameters" and "procedure to diagnosis edits" and provides definitions for these terms, as well as "modifier indicators." Another commenter notes that the subclause lists some but not all types of bundling processes and recommends adding a reference to and a definition of "unit frequency limitations."
Agency Response: The department does not believe that the suggested language is necessary as it has changed the rule to require the provision of all applicable bundling processes. The basic requirement of the rule is to ensure that physicians and providers have sufficient information to determine the payment to be made in accordance with the contract, no matter on what basis the parties agree to determine payment.
§11.901(10) & (11)(B) [§3.3703(a)(20)(D), (a)(21)(B)]: Some commenters indicate that circumstances beyond a carrier´s control might make it impossible to comply with the 60-day notice of changes in fees and claims processes, and request an exception for coding changes that are beyond the carrier´s control, such as those prescribed by the Centers for Medicare and Medicaid Services (CMS) or the AMA. The commenter notes that CMS issues retroactive coding changes or provides insufficient lead time to meet the requirement. Other commenters believe that retroactive revisions should not be allowed and that mutual agreement between the carrier and physician or provider should be required for any amendments to be effective. Another commenter requests that this provision be changed to 30 days. Another commenter asked for an explanation of how the 60-day notice period in paragraph (D) reconciles with the 90-day compliance period in paragraph (F). Another commenter states that software is developed to check billings and to be responsive to changes in billing practices encountered over time. A 60-day notice period might prevent carriers from catching up to innovative changes in billing practices, which might prove unfair to carriers and cause health care costs to rise.
Agency Response: The department acknowledges the concerns regarding the timing of changes in coding and fee schedules but disagrees that the rule should be changed. Where parties have agreed to use source information outside the control of the carrier as the basis for the carrier's fee computation, the information the rule requires carriers to provide is the identity of the source and the procedure by which the physician or provider may readily access the source. A change to either of those items, or to any factor within the carrier's direct or indirect control, would trigger the 60-day notice requirement. Any change to the source information outside the control of the carrier, however, would not be a change to the carrier's claims payment policies or procedures or to the information required by this rule, and would not require 60 days notice under Article 3.70-3C, §3A(k) and 28 TAC 11.901(10)(D). However, if the carrier makes a change to a claim processing or payment procedure (such as changing the fee payment from 120% of Medicare to 110%), that would require a 60-day notice in order to be effective. Although the rule does not require a carrier to provide notice of changes made by an outside source, the parties are free to create such a duty by contract, or to agree on effective dates different from those set by the outside source. The department will continue to monitor this practice to determine if future rulemaking is warranted.
§11.901(10) and (11) [§3.3703(a)(20) and (21)]: Some commenters support alternative two as being more reasonable and in line with Attorney General Opinion No. JC-0502. The commenters assert that alternative one seeks information that goes beyond the scope of TDI's statutory authority and the attorney general's opinion. The commenters support the provision of information only on request, as proposed in alternative two, as consistent with their current procedures. Other commenters support TDI´s efforts to promulgate rules which assist providers in determining whether reimbursement has been made in accordance with the contract.
§11.901(10) [§3.3703(a)(20)] - Misuse of Information and Fraud: Some commenters assert that alternative one does not protect carriers from the potential of provider misuse of the disclosed information. The commenters believe that the proposal will result in an increase either in inflated provider charges or fraudulent billing activities by a few providers, causing a financial impact on the health care system. The commenters believe that disclosing coding guidelines to these particular providers will make it easier to submit fraudulent claims. A commenter asserts that disclosure of fee schedules and disclosure of claims review and fraud detection policies are two distinct issues, which should be addressed independently. Fee schedules should be disclosed, but the details of claims review and fraud detection processes should not be disclosed. To counter the possibility of the information being used for fraud, one commenter suggests that the carrier be allowed to provide only a summary description of the bundling and coding policies and, upon written request, an explanation of the methodology of the coding decision on an individual claim.
Agency Response: The intent of the rule is to ensure that physicians and providers are able to determine what they should be paid in accordance with the contract. If a carrier suspects that fraud is occurring, it has an obligation to advise the department and other authorities so that action can be taken. Because the Insurance and Penal Codes contain specific provisions concerning fraud, the department declines to include language regarding penalties in this rule. The rule also does not prohibit a carrier from including additional remedies for inappropriate disclosure in its provider contracts.
§11.901(10)(A)(ii) [§3.3703(a)(20)(A)(ii)]: A commenter recommends deletion of clause (ii) concerning nonstandard codes since HIPAA requires deletion of such codes. Other commenters recommend that the rule reference HIPAA in connection with standard transactions and that language be included allowing the rule to change in accordance with changes in the law. A commenter agrees that if standard coding methodology is not being used, then disclosure may be needed. One commenter says the rule should either specify an inclusive list of adjudication methodologies to be addressed, or disallow nonstandard billing practices. A commenter notes that the terms HCPCS and ICD-9-CM codes are commonly understood, but should still be defined in the rule.
§11.901(10)(A)(v) & (vi) [§3.3703(a)(20)]: A commenter states that the provisions could be interpreted to require more information than intended, including the disclosure of the entire claims processing manual, internal communications, changes in the claims processing system and other internal processes not related to claims payment. The commenter says this would be cumbersome and unnecessary and would disrupt on-going system improvement, innovation and updating. The commenter recommends limiting the requirement to disclosure of claims payment information. Another commenter suggests revising the requirements to focus on claims payment rather than claims processing. The commenter believes that disclosure of claims processing requirements is overly broad and would inundate physicians and providers with highly technical manuals that would be of little value in understanding reimbursement. The commenter suggests deleting the broad phrase "processing of claims" and instead concentrating on disclosure in the context of a claim adjudication inquiry.
Agency Response: The purpose of the rule is to assure the delivery of sufficient information for a skilled reasonable person to make a determination of the payment to be made under the contract. The department does not intend the rule to place an undue burden on carriers or to inundate preferred providers with unnecessary information. The department tailored the adopted rule to address only those aspects of claims processing that achieve this purpose.
§11.901(11) [§3.3703(a)(21)]: Some commenters recommend that alternative two define terms and require requests to be in writing to avoid disputes as to whether and when a request was made. Some commenters ask that the carrier be given 30 days from the date of its receipt of the written request to provide the information. If Internet access is not allowed, the commenter asks that the request for information be in writing to protect the carrier´s proprietary information and validate the requestor´s right to receive the information.
Agency Response: The department agrees with commenters´ concerns that disputes regarding receipt of requests for the required information should be avoided. A physician or provider may submit a request by e-mail, facsimile or other reasonable and verifiable means in order to receive the required information. Because the department is adopting alternative one, definition of terms for alternative two is not necessary.
§11.901(10)(F) and (11)(E) [§3.3703(a)(20)(F) and (21)(E)] - Effective date: If alternative one is selected, some commenters recommend an extension of the 90-day time frame for compliance. Specifically, one commenter requests 180 days to comply, while another commenter suggests January 1, 2003. Some commenters request that compliance with alternative two be at least 90 days, with one commenter requesting 180 days, from the effective date of the rule to provide carriers sufficient time to revise contracts. On subparagraph (E), a commenter suggests that carriers be given 30 days from the effective date to bring contracts into compliance.
Agency Response: The department acknowledges the possibility that some carriers will need time to develop the procedures necessary to comply. Accordingly, the rule requires a carrier to provide the required information, in existing contracts, to the physician and provider on the later of the 90 th day after the effective date of this rule or the 30 th day after the date the carrier receives the physician´s and provider's request. For contracts entered into or renewed after the rule takes effect, beginning on the 90 th day after the effective date of the rule, carriers must provide the required information upon request contemporaneously with other contractual materials.
§11.901(11) [§3.3703(a)(21)]: A commenter believes that alternative two allows the physician or provider to request entire fee schedules, which will be costly to provide. The commenter asks that providers be limited to requesting fee schedules for the providers' specialty and a specific number of codes within that specialty. Another commenter asks that the carrier only have to provide the top 25 or 50 CPT codes, based on the provider's practice or specialty, but allow for written requests of any additional CPT codes. Another commenter suggests that alternative two would be more manageable if the ability to request information of the carrier was claim specific.
A commenter states that it would be extremely expensive to require carriers to give every physician and provider a specific summary of benefits tailored to that specific physician or specialty. The commenter believes it also would not be necessary, because each policy governs payments under the policy and it is only the amount of discount from the providers´ fee schedules that determines the level of compensation.
Agency Response: The department does not intend the rule to place an undue burden on carriers or to inundate physicians and providers with unnecessary information. Based on comments, the department is adopting a modified version of alternative one, which requires that a carrier provide a fee schedule related only to the services reasonably expected to be provided under the physician´s and provider´s contract with the carrier. A carrier must also provide a toll-free number or electronic address to allow a physician and provider to access information regarding services not included in the fee schedule initially provided. The department acknowledges that there will be expenses involved in providing fee schedules to physicians and providers, and addressed this issue in the preamble to the proposed rule. However, in the adopted rule, the department has mitigated the expenses involved by allowing the carrier flexibility to provide the required information by alternative means and only upon request. It is the department's intent that physicians and providers receive sufficient information for a skilled reasonable person to determine the payment to be made in accordance with their contract. The department disagrees with the last portion of this comment. Due to the nature of the complaints received, the department believes that the availability of a fee schedule to physicians and providers is necessary.
§11.901(10)(A)(i)(II) [§3.3703(a)(20)(A)(i)(II)]: A commenter inquires whether carriers can use existing toll-free numbers.
Agency Response: Carriers may use an existing toll-free number.
§11.901(10)(A)(i)(II), (v) & (vi) [§3.3703(a)(20)(A)(i)(II), (v) & (vi)]: A commenter points out that certain factors are included in the proper payment of claims that do not include valuing the claims or correct coding of the claim. These factors include a medical director determining a claim is not medically necessary or a carrier identifying a pattern of fraudulent billing. The commenter notes that these type of factors are not included in the scope of the rule. A commenter contends that coding requirements are specific to diagnosis, procedure code, severity level, and treatment guidelines, while claims are adjudicated based on the interrelationship of multiple elements, and that compliance with the provision will be difficult. The commenter acknowledges that carriers can provide the name of the software and a summary of the coding guidelines to determine applicability but may not be able to relate each coding factor back to each fee schedule.
Agency Response: It is the department´s intent that physicians and providers receive sufficient information so that a skilled reasonable person can determine the payment to be made under the terms of the contract. The department recognizes that the commenter´s examples of determining medical necessity and identifying fraudulent billing patterns, as well as other factors, may affect the actual amount of reimbursement, but these factors are outside the scope of this rule as well as the statute. The department believes that allowing the information to be distributed electronically and upon request addresses the concerns regarding any potential burden associated with changing the CPT codes or internal systems and processes.
§11.901(10)(A)(vii) [§3.3703(a)(11) & (20)(A)(vii)]: A commenter believes that the use of the phrase "including but not limited to" is ambiguous and requires carriers to guess about the possible existence of other laws that are not specifically cited. The commenter requests deletion of the phrase or the inclusion of the specific citation to all statutes and rules that TDI believes are applicable to the prompt payment of clean claims. Another commenter recommends deletion of clause (vii ) as carriers are already required to comply with the provisions of Art. 20A.18B.
Agency Response: The department has deleted clause (vii) as unnecessary since the requirement is already in paragraph (7). A carrier is required to comply with all applicable laws and rules whether or not specified, including Art. 20A.18B. "Including" is a term of enlargement and not of limitation or exclusive enumeration, and the department has accordingly deleted the phrase "but not limited to."
§11.901(10)(B)(iii): A commenter suggests changing the last part of the clause to "access the source as referenced by the health plan."
Agency Response: The department does not believe the addition of this language is necessary and declines to make the change. The provision already states that the contract must identify and explain the procedure by which the physician or provider can readily access the source.
§11.901(10)(A)(iii) [§3.3703(a)(20)(A)(iii)]: Some commenters want the rule to require carriers to inform the physician or provider of updates to their bundling processes. Another commenter asserts that downcoding of a clean claim is a violation of the prompt pay rules.
§11.901(10)(B)(ii) and (iii) [§3.3703(a)(20)(B)(ii) and (iii)]: A commenter recommends that clauses (ii) and (iii) be combined into (ii). Two commenters recommend the removal of references to Medicaid or Medicare fee schedules because of the potential for confusion.
Agency Response: The department has changed the rule to permit the delivery of the information by any reasonable means upon request from the physician or provider. The department does not agree that the use of Medicaid and Medicare fee schedules as examples creates confusion as those schedules are common benchmarks for compensation in contracts between carriers and physicians or providers.
§11.901(10)(B) [§3.3703(a)(20)(B)]: A commenter suggests that if other documents are utilized to convey changes regarding reimbursement provisions, these documents need to be provided to the physician or provider at the time the contract is submitted for initial review rather than at the time of execution of the contract. Another commenter requests that the additional documents be provided at least 60 days before the contract is presented for execution.
Agency Response: Adopted alternative one provides for delivery of required information, including references to outside sources, upon request from the physician or provider. For contracts entered into or renewed on or after the effective date of these amendments, the carrier must provide the required information contemporaneously with other contractual materials. The department reminds commenters that any amendments, revisions or substitutions to the information are not effective unless the carrier provides at least 60 days written notice.
§11.901(10)(B)(iii) [§3.3703(a)(20)(B)(iii)]: A few commenters suggest that, along with HMOs, delegated networks, delegated entities and delegated third parties as defined by statute (HB 2828) should be referenced. Some other commenters prefer alternative two over alternative one, but see a fundamental flaw in that neither includes a network entity.
§11.901(10)(C) and (11)(D) [§3.3703(a)(20)(C), (a)(21)(D)]: Some commenters request that the references to copyright laws and licensing agreements be removed because they are inconsistent with HB 610 which provides for the disclosure of claims processing information. These commenters are concerned that a carrier will use these laws or agreements to avoid their disclosure obligations. In the alternative, if the copyright and licensing exclusions are maintained, a commenter requests deleting the words "reasonable" and "training," and make no other changes. The commenter also suggests that any licensing exclusions should only be effective for one year.
Agency Response: The department disagrees that references to copyrighted or other proprietary information should be deleted. The rule contains sufficient detail to mandate that any entity asserting a copyright or other similar interest must provide the degree of information necessary to inform a physician or provider about fee schedules and coding procedures. The rule does not, however, preclude carriers and physicians or providers from engaging in a dialogue concerning the adequacy of any particular piece of information furnished, and the department expects that parties will air and resolve their concerns without the department´s involvement. Comments received indicate that some carriers are already providing this information without any problems of this nature. The words "reasonable" and "training," also contained in subparagraph (A), are useful in describing the required level of detail. It would not be appropriate to limit licensing exclusions to only one year, as copyright or other proprietary interests may not be so restricted.
§11.901(10)(C) and (11)(D) [§3.3703(a)(20)(C), (21)(D)]: Some commenters note that the provisions of §11.901(11) requiring the carrier to provide the name, edition, and model of software may not be sufficient to meet the requirements of the law. The commenters also note that there is no provision in either alternative for reasonable access to or availability of the software.
Agency Response: The department appreciates the commenters´ concern that the rule does not guarantee access to any particular software. The department also recognizes that some carriers are subject to licensing agreements. However, a carrier can reveal the function any computer program is intended to perform without violating a licensing agreement. Any other conclusion suggests that the carrier is ceding control of the claims payment process to its software vendor, which is neither likely nor acceptable. A summary is simply a presentation or collection of less than the entire material included in a particular category. Adopted alternative one establishes a standard that the information submitted to the physician and provider, whether or not in summary form, must suffice to enable a skilled reasonable person to determine the payment to be made according to the terms of the contract. A carrier providing this level of detail will be in compliance. The rule allows carriers flexibility to meet this requirement by utilizing means agreeable to both parties.
§11.1901(10)(D) and (11)(B) [§3.3703(a)(20)(D), (a)(21)(B)]: A commenter suggests defining "routine changes" that would not require the 60-day notice and "material changes" that would require the 60-day notice. According to the commenter, routine changes occur frequently and are accepted as the norm by physicians and providers. These changes typically have a minor impact on the physician or provider. On the other hand, material changes are intended to alter substantially the overall methodology or reimbursement level of the fee schedule.
A commenter objects that alternative two only requires the provision of notice for "material" changes without any guidance as to what such "material" changes may be.
Agency Response: The department has adopted alternative one, which does not contain the term "material changes." The standard in the rule is that any amendment, revision or substitution of the required information that could make a difference in the payment to be made under the contract is subject to the 60-day notice requirement in (D). However, as noted in response to a previous comment, any change to the source information outside the control of the carrier, such as an incremental change to a fee schedule or coding guideline, would not be a change to the carrier's claims payment policies or procedures or to the information required by this rule, and would not require 60 days notice under Article 3.70-3C, §3A(k) and 28 TAC §11.901(10)(D).
§11.901(10)(D) [§3.3703(a)(20)(D)]: Some commenters request inclusion in this subparagraph of a reference to policies and procedures, such as turning an edit off or on or adopting a new policy based on recent FDA approval of a procedure or equipment, as they may have a direct impact on claims payment.
§11.901(10)(F) [§3.3703(a)(20)(F), (a)(21)]: A commenter is concerned that the use of the phrase "these amendments" may be confusing and that some carriers may resist renewing or amending existing contracts to avoid disclosure of the required information. The commenter suggests that the language be changed to "this paragraph." Another commenter suggests that the first sentence be deleted to clarify that the requirement for disclosure applies to currently contracted physicians. A commenter requests that, if alternative two is adopted, the provisions of §11.901(10)(F) be included in the language of the rule so that the amendments will apply to ongoing contracts as well as contracts entered into after the effective date of the rule.
Agency Response: The rule applies to all carriers as of the effective date of the rule. Contracts entered into or renewed on or after the effective date of this rule must comply with the provisions of paragraph (10). HMOs operating under existing contracts must provide the required information to the physician or provider in accordance with subparagraph (F).
§11.901(10)(G)(i) [§3.3703(a)(20)(G)(i)]: Some commenters suggest that, along with the disclosures mentioned, physicians and providers should be allowed to disclose the information for purposes of legislative or regulatory change, civil actions, or other legal remedies and purposes. Another commenter b´ concerns are outside the scope of this rule. If, for example, someone were required to produce this information as part of a civil action, other considerations, such as the contract believes that this subparagraph improperly limits the physician's use of the information to something less than is allowed by law.
Agency Response: The department disagrees. The comments between the parties, private confidentiality agreements, contractual or civil penalties, would govern disclosure of this information for purposes other than determining the payment to be made under the contract.
§11.901(10)(G)(i) & (ii) and (11)(C) [§3.3703(a)(20)(G) and (21)(C)]: Some commenters believe that the clauses are too broad and may allow the sharing of fee schedules with persons that may not need or have a right to the information, as well as the disclosure of information that should otherwise be treated as confidential. The commenters suggest deleting the phrase "or other business operations" from the clauses. A few commenters suggest limiting the use and disclosure to entities that directly support the provider´s billing process. A few commenters request that the department amend both alternatives to allow carriers to immediately terminate contracts with providers who fail to comply with the restrictions on disclosure. Another commenter suggests that alternative two include the specific prohibition from improper disclosure found in alternative one.
Agency Response: The department agrees that "other business operations" is overly broad and has deleted the phrase. Regarding the potential effect on discounts, the department understands that implementation of the statute will likely result in physicians and providers receiving more information during the contracting process than they currently do; however, the statute requires full disclosure of a carrier´s claims payment policies and procedures. The department declines to include language regarding penalties for improper disclosure, but notes that nothing in the rule prohibits a carrier from negotiating a contractual remedy.
§11.901(10) & (11) [§3.3703(a)(20) and (21)] ­ Delegation Issues: A commenter suggests changing the paragraph to only require disclosure of information that is actually governed by the contract since a PPO network would not be able to disclose the payment processes of carriers as they are not privy to that information. One commenter believes that these subsections are premised on the idea that the insurance company determines the fee schedules and fee guidelines. The commenter considers this reasoning flawed and argues that the typical PPO contract is based on fee schedules maintained by the healthcare provider. A commenter does not believe that a PPO or a network entity can provide information that would meet the reasonable person standard set forth in paragraph (20). The commenter explains that because of such factors as covered and non-covered services, deductibles, co-payments, co-insurance, amounts paid for other coverages, it is not possible to provide sufficient information in the contract to allow for all contingencies.
Agency Response: Although comments on this delegation issue were only received in reference to §3.3703, the department recognizes that this issue is applicable to §11.901 and HMOs. The department understands there are a variety of contractual arrangements, some involving the participation of delegated entities and delegated third parties who have assumed the responsibility for claims payment. While an HMO may delegate to a delegated entity or delegated third party the duty to provide reimbursement information, the HMO remains ultimately responsible for ensuring that its contracted delegated entities provide the information set out in this rule to their contracting physicians and providers. The factors referred to in the comment are outside the scope of this rule, as noted in Section 3 of this adoption order.
The amendments are adopted under the Insurance Code Article 20A.18B and §36.001. Article 20A.18B(o) gives the Commissioner the authority to adopt rules as necessary to implement Article 20A.18B. Article 20A.18B(i) provides that an HMO shall make available to a contracting physician or provider its claims processing policies and procedures. The Commissioner´s authority to adopt rules relating to the disclosure of claims payment processes such as fee schedules, bundling processes, and downcoding policies was clarified by Attorney General Opinion No. JC-0502. The opinion states that the Texas Department of Insurance is authorized to promulgate rules to require preferred provider benefit plans and HMOs to disclose their fee schedules, bundling processes, and downcoding policies. Section 36.001 provides that the Commissioner of Insurance may adopt rules to execute the duties and functions of the Texas Department of Insurance as authorized by statute.
(5) regarding posting of complaints notice in physician/provider offices as described in the Insurance Code Article 20A.18A(i). A representative notice that complies with this requirement may be obtained from the Texas Department of Insurance, HMO/UR/QA Group, P.O. Box 149104, Austin, Texas 78714-9104;
(10) entitling the physician or provider upon request to all information necessary to determine that the physician or provider is being compensated in accordance with the contract. A physician or provider may make the request for information by any reasonable and verifiable means. The information must include a level of detail sufficient to enable a reasonable person with sufficient training, experience and competence in claims processing to determine the payment to be made according to the terms of the contract for covered services that are rendered to enrollees. The HMO may provide the required information by any reasonable method through which the physician or provider can access the information, including e-mail, computer disks, paper or access to an electronic database. Amendments, revisions or substitutions of any information provided pursuant to this paragraph must be made in accordance with subparagraph (D) of this paragraph. The HMO shall provide the fee schedules and other required information by the later of the 90th day after the effective date of this paragraph or the 30th day after the date the HMO receives the physician´s or provider´s request.
(v) a description of any other applicable policy or procedure the HMO may use that affects the payment of specific claims submitted by or on behalf of the contracting physician or provider, including recoupment; and
(vi) any addenda, schedules, exhibits or policies used by the HMO in carrying out the payment of claims submitted by or on behalf of the contracting physician or provider that are necessary to provide a reasonable understanding of the information provided pursuant to this paragraph.
(D) No amendment, revision, or substitution of any of the claims payment procedures or any of the information required to be provided by this paragraph shall be effective as to the contracting physician or provider, unless the HMO provides at least 60 calendar days written notice to the contracting physician or provider identifying with specificity the amendment, revision or substitution. Where a contract specifies mutual agreement of the parties as the sole mechanism for requiring amendment, revision or substitution of the information required by this paragraph, the written notice specified in this section does not supersede the requirement for mutual agreement.
(F) This paragraph applies to all contracts entered into or renewed on or after the effective date of this paragraph. Upon receipt of a request, the HMO must provide the information required by subparagraphs (A) - (D) of this paragraph: