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Claims Processing - April 30, 2008

Agenda - April 30, 2008

  • Antitrust Statement - Review of Ground Rules by Jennifer Ahrens, Associate Commissioner, Life, Health & Licensing
  • 2008 TACCP Report Status by Katrina Daniel, Special Advisor for Policy Development, Life, Health & Licensing
  • Legislative Updates: HB 472, HB 522, HB 1594, SB 1731 by Doug Danzeiser, Deputy Commissioner, Regulatory Matters and Dianne Longley, Director of Research and Analysis, Data Collection.

TACCP Calendar of Events

  • April 30, 2008, Distribute the first draft of the 2008 report - Teleconferencing available
  • July 23, 2008, Distribute the final draft to members
  • July 30, 2008, Review final draft of the 2008 report
  • August 6, 2008, Comments/Edits due on final draft of report
  • August 13, 2008, Revisions completed/send to the Commissioner
  • August 20, 2008, Report to the printer
  • September 1, 2008, 2008 TACCP report due to Legislature

Meeting Notes


Jennifer Ahrens welcomed the TACCP members and observers and read the antitrust statement and meeting ground rules.

Legislative Updates:

House Bill 472 - The regulation of third party administrators transferred to the Financial Program due to the reporting requirements in the bill. Kevin Brady in Financial will address questions regarding the rules.

House Bill 522 - The Department will temporarily postpone enforcing the implementation of a new ID card process for a Texas pilot under the bill. Changes are forthcoming in the federal 5010 rule, CAQH/CORE Phase 2 rule, and the Medicaid's ID card program will be deploying.

House Bill 1594 - The Department is interested in how expedited credentialing is working in the industry. A member asked the Department what complaint is primarily received. Staff indicated the primary complaint is that carriers aren't treating physicians as a group. Members discussed the fact that the issue with the definition of group as included in HB 1594 will be resolved in the 81st Legislative Session.

Senate Bill 1731 - The reimbursement data collection rules are ready and awaiting the Department's negotiations with AMA on a contracting rights issue.

2008 TACCP Report:

Overview - The report focuses on the TACCP activities and is reformatted from previous years for easier reading. Thus far, only two members submitted drafts/comments for the report.

Member Comments - Discussion included the following:

  • Addition of Background Information in the Recovery of Overpayment Section - The Department needs issues provided from the providers' and carriers' perspectives. A member offered to send examples of recovery of overpayments that are not really overpayments;
  • Lack of a Definition for Material Misrepresentation Presents Problems - Providers are looking back more than 180 days and language in the report that states it is allowed. A provider member commented that it seems to be open-ended. Carriers are able to look back many years. Members are encouraged to present a perspective on this issue to the Department for inclusion in the report. A suggestion is that comments be focused on specific types of look-back or audit issues to avoid putting a time limitation on fraud look-backs;
  • Suspicion of Irregular Activities - A member commented that plans had an out if they suspected irregular activities. Plans can not tip off a person submitting fraudulent bills by holding off paying claims. If the claim is unclean, they can treat it like the statute or rules allow. It is important to note that it is expensive for carriers to maintain fraud units. There is a legitimate middle ground where inquiries are made due to suspicious activities;
  • Silent PPO - It was suggested that the Department include a review of the collaborative work completed last session and the Department's statutory basis for taking enforcement action.
  • Medicare Advantage Marketing - A member commented that this issue does not seem to relate to claims processing. This issue, however, involves agent behavior and was addressed in one of the committee meetings. It was suggested that the report clarifies that the Legislature has no regulatory authority over these plans, but can regulate the agents' behavior;
  • Outside Meeting Groups - A member suggested including meeting information for various groups meeting outside the formal TACCP forum to attempt to resolve some of these issues. A member agreed to submit draft language; and
  • Comment and Review Periods - Several drafts will be sent to members for review. The schedule is as follows: (dates in bold with * - items due to TDI from TACCP member)
  • * May 14th - comments for second draft due to TDI staff
  • May 23rd - second draft sent to members
  • * July 14th - final comments due to TDI staff
  • July 23rd - final draft to members
  • * July 30th - discuss final report in quarterly meeting

Open discussion:

No issues were raised.

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Last updated: 9/28/2015