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Technical Advisory on Claims Processing (TACCP)

Agenda - September 20, 2007

  • Antitrust Statement, Review of Ground Rules by Jennifer Ahrens, Associate Commissioner, Life, Health & Licensing
  • Clean Claims Rules / National Provider Identifier (NPI) by Susan Carr, Staff Attorney, Policy Development Counsel and Katrina Daniel, Special Advisor for Policy Development, Life, Health and Licensing
  • Silent PPO Proposed Rule by Susan Carr and Jennifer Ahrens
  • SB 1884 - Calculation of Underpayment Penalties by Jack Evins, Director, Advertising Unit, Consumer Protection
  • Lunch
  • Prompt Payment Penalties Settlements by Doug Danzeiser, Deputy Commissioner, Regulatory Matters, Life, Health & Licensing and Katrina Daniel
  • SB 1731 - Balance Billing / Network Adequacy Study by Katrina DanielRecovery of Overpayments in Cases of Fraud or Material Misrepresentation by Doug Danzeiser
  • Discuss Dates for Next Meeting Group

Meeting Notes

New Committee Members:

Jennifer Ahrens introduced new committee members. The new appointees included Humana, the Texas Pharmacy Association, and the Texas Hospital Association. Ms. Ahrens informed the committee of the new ground rules that permit open discussion from invited guests at the end of each agenda item, and read the anti-trust statement to all attendees.

Clean Claims Rules/National Provider Identifier (NPI):

Susan Carr opened discussion on the NPI and noted that new clean claims processing rules were adopted, allowing for inclusion of the NPI on claim forms. Ms. Carr asked for comments on NPI issues.

One provider member stated that some surgeons do not have NPI numbers, so the system is not working as well for some providers, such as anesthesiologists. A few filed paper claims. One member mentioned that the Veterans Administration does not use NPI numbers. Since the registry is open (anyone can obtain a NPI number), the possibility of abuse exists.

A carrier member stated that they met with the Texas Medical Association and contingency plans are working.

Frequently Asked Questions (FAQs):

Ms. Carr mentioned that the FAQs on the new clean claim rules should be posted to the Department's website soon. Katrina Daniel indicated the FAQs should go up within a few days pending some questions that need to be resolved. Some health plans are still requiring the type 2 NPI numbers.

Silent PPOs:

Ms. Ahrens mentioned that the Department posted draft rules before the legislative session regarding silent PPOs in response to TIC Section 1301.056. HB 839 was introduced to address silent PPOs, but did not pass. So far during the 2007 calendar year, only one of six complaints regarding silent PPOs was justified. No notation indicates whether the complaints were self-funded or automobile plans rather than the 1301 plans.

One provider member stated that most silent PPOs are self-funded. Valerie Brown noted that although the Department does not regulate self-funded plans, we would continue to note complaints for reporting purposes.

Ms. Ahrens expressed the need to address the silent PPO issue in the TACCP 2008 report to the legislature.

A member asked if anyone has heard of instances where the physician is paid as if they were in-network, but the patient doesn't receive the price break/percentage difference of the in-network rate. Another provider member stated that sometimes a physician is paid less, but the patient doesn't get the benefit of the lower price. A provider member commented that if the Department sees this type of trend then action needs to be taken and would like the Department to keep this in mind.

SB 1884 Calculations of Underpayment Penalties:

Jack Evins opened the discussion on SB 1884. He said that the bill changed the way penalties are calculated. Jack mentioned that an informal working draft of the rules implementing these changes have been posted on the Department's website. The comment period ends on September 26, 2007, and should be directed to Ms. Daniel.

SB 1731 Balance Billing/Network Adequacy Study:

Ms. Daniel opened discussion on the implementation of SB 1731 and indicated that Dianne Longley has been working on implementation. Over the last few months, the Department has worked with stakeholders. The advisory committee appointments established by SB 1731 should be completed by mid-October and the first meeting should be during late of October. The meetings are open to anyone wishing to attend.

The timeframe for implementation of this bill is very tight. The legislation required one year's data; however, the Department anticipates having six-months of data to report before the Legislature reconvenes. The Department is working with the Legislature and informing them of the Department's plan to report the data in six-month periods. One carrier member asked what kinds of rules were anticipated to be associated with the bill -- Department staff responded that no rules are anticipated at this point, the Department will only conduct data calls.

Prompt Payment Penalties Settlements:

Doug Danzeiser stated that the Department has been informed that providers and payors have a desire to resolve/settle large numbers of claims in aggregate/global settlements and is concerned about whether appropriate penalties have been paid. The Insurance Code that prohibits the waiving of penalties and the Department posted a bulletin in August 2005 to address this issue. Mr. Danzeiser stated that the penalty and payment should be made concurrently.

A carrier member stated that it is not always clear whether a penalty applies. Another carrier member stated that claims can go back several years and it is difficult to apply the applicable fee schedule. One carrier member made a distinction between negotiating penalties and negotiating a package settlement. Requiring two settlements, one on the fee and one on the penalties, makes the system unravel and become more cumbersome. One participant thought that the intent of the law was to provide for negotiation of penalty on the front end.

Recovery of Overpayments in Cases of Fraud or Material Misrepresentation:

Mr. Danzeiser stated that the Department has received complaints that carriers are auditing providers after 180 days and seeking overpayments. Under the TDI rules, if an audit takes place over 180 days after a claim, an overpayment can only be collected if there is fraud or material misrepresentation. Pharmacists are having issues with compliance.

This issue will be on the agenda for the next meeting. Members will collect data to bring to the next meeting.

Next TACCP Meeting:

Ms. Ahrens suggested meeting quarterly with the next meeting in January to develop report issues, followed by an April meeting. She is tentatively scheduling July to discuss the draft report and October to discuss the final report to the Legislature.
A provider member requested the auditing issue (pay, deny, audit) at the next meeting, stating that records are continually requested, which may be a HIPAA violation. A provider member stated that she is getting calls from physicians on expedited credentialing and wants to know how HB 1594 is being implemented. A carrier member asked that SB 1731 be added to the January meeting agenda.

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Last updated: 9/6/2014