Tex.
Ins. Code Section 38.004
Balance Billing Prohibition Report
(a)
The department shall, each biennium, conduct a study on the impacts of S.B. No. 1264, Acts of the 86th Legislature, Regular Session, 2019, on Texas consumers and health coverage in this state, including:(1)
trends in billed amounts for health care or medical services or supplies, especially emergency services, laboratory services, diagnostic imaging services, and facility-based services;(2)
comparison of the total amount spent on out-of-network emergency services, laboratory services, diagnostic imaging services, and facility-based services by calendar year and provider type or physician specialty;(3)
trends and changes in network participation by providers of emergency services, laboratory services, diagnostic imaging services, and facility-based services by provider type or physician specialty, including whether any terminations were initiated by a health benefit plan issuer, administrator, or provider;(4)
trends and changes in the amounts paid to participating providers;(5)
the number of complaints, completed investigations, and disciplinary sanctions for billing by providers of emergency services, laboratory services, diagnostic imaging services, or facility-based services of enrollees for amounts greater than the enrollee’s responsibility under an applicable health benefit plan, including applicable copayments, coinsurance, and deductibles;(6)
trends in amounts paid to out-of-network providers;(7)
trends in the usual and customary rate for health care or medical services or supplies, especially emergency services, laboratory services, diagnostic imaging services, and facility-based services; and(8)
the effectiveness of the claim dispute resolution process under Chapter 1467 (Out-of-network Claim Dispute Resolution).(b)
In conducting the study described by Subsection (a), the department shall collect settlement data and verdicts or arbitration awards, as applicable, from parties to mediation or arbitration under Chapter 1467 (Out-of-network Claim Dispute Resolution).(c)
The department may not publish a particular rate paid to a participating provider in the study described by Subsection (a), identifying information of a physician or health care provider, or non-aggregated study results. Information described by this subsection is confidential and not subject to disclosure under Chapter 552 (Public Information), Government Code.(d)
The department:(1)
shall collect data quarterly from a health benefit plan issuer or administrator subject to Chapter 1467 (Out-of-network Claim Dispute Resolution) to conduct the study required by this section; and(2)
may utilize any reliable external resource or entity to acquire information reasonably necessary to prepare the report required by Subsection (e).(e)
Not later than December 1 of each even-numbered year, the department shall prepare and submit a written report on the results of the study under this section, including the department’s findings, to the legislature.
Source:
Section 38.004 — Balance Billing Prohibition Report, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.38.htm#38.004 (accessed May 18, 2024).
