Relating to health benefit plan preauthorization requirements for certain health care services and the direction of utilization review by physicians.

Contracts

• UR Vendor Agreements (MSAs): You must immediately amend Master Services Agreements with third-party UR vendors. Insert a warranty clause requiring that all Medical Directors hold a full, unrestricted license to practice medicine in Texas. Explicitly prohibit the use of physicians holding only an "administrative medicine" license (Occupations Code Sec. 155.009).
• Provider Manuals: Update manuals to reflect the elimination of the six-month evaluation period and the removal of the June rescission window.

Hiring/Training

• Medical Director Audits: Conduct an immediate licensure audit of all internal and external physicians directing UR. If a director holds an administrative license, they must be removed from the UR role immediately.
• Rescission Reviewers: Staffing for retrospective reviews to rescind exemptions must be adjusted. You must ensure reviewers are of the same or similar specialty as the provider being reviewed.

Reporting & Record-Keeping

• Data Aggregation Logic: IT systems must be reprogrammed to aggregate preauthorization data across all affiliated plans. You can no longer silo data by specific plan or line of business when calculating a provider's 90% approval rate.
• Rescission Notice Packets: When notifying a provider of a rescission, you must now attach the specific data for the 5-to-20 claim random sample used to make the determination.
• New Annual Report: Begin internal tracking of:
• 1. Total exemptions granted.
• 2. Total exemptions rescinded/denied.
• 3. Total IRO requests regarding exemption disputes and their outcomes.

Fees & Costs

• Maintenance Taxes: Expect a marginal increase in maintenance tax assessments to cover the $1.05 million cost for TDI to build the new reporting database.
• Litigation Risk: The Texas Medical Board (TMB) is now authorized to levy administrative penalties against physicians who direct UR without "medical justification." This increases the cost of insuring or indemnifying your Medical Directors.