| (a) Itemized statements. A hospital shall adopt, implement,
and enforce a policy to ensure that the hospital complies with the
Health and Safety Code (HSC), §311.002 (Itemized Statement of
Billed Services).
(b) Audits of billing. A hospital shall adopt, implement,
and enforce a policy to ensure that the hospital complies with HSC, §311.0025(a)
(relating to Audits of Billing).
(c) Balance Billing.
(1) A hospital may not violate a law that prohibits
the hospital from billing a patient who is an insured, participant,
or enrollee in a managed care plan an amount greater than an applicable
copayment, coinsurance, and deductible under the insured's, participant's,
or enrollee's managed care plan or that imposes a requirement related
to that prohibition.
(2) A hospital shall comply with Senate Bill 1264,
86th Legislature, Regular Session, 2019, and with related Texas Department
of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901
- 21.4904 (relating to Disclosures by Out-of-Network Providers) to
the extent this subchapter applies to the hospital.
(d) Complaint investigation procedures.
(1) A complaint submitted to HHSC's Complaint and Incident
Intake relating to billing must specify the patient for whom the bill
was submitted.
(2) Upon receiving a complaint warranting an investigation,
HHSC shall send the complaint to the hospital requesting the hospital
to conduct an internal investigation. Within 30 days of the hospital's
receipt of the complaint, the hospital shall submit to HHSC:
(A) a report outlining the hospital's investigative
process;
(B) the resolution or conclusions reached by the hospital
with the patient, third party payor or complainant; and
(C) corrections, if any, in the hospital's policies
or protocols which were made as a result of its investigative findings.
(3) In addition to the hospital's internal investigation,
HHSC may also conduct an investigation to audit any billing and patient
records of the hospital.
(4) HHSC shall inform in writing a complainant who
identifies himself by name and address:
(A) of the receipt of the complaint;
(B) if the complainant's allegations are potential
violations of the Act or this chapter warranting an investigation;
(C) whether the complaint will be investigated by HHSC;
(D) if the complaint was referred to the hospital for
internal investigation;
(E) whether and to whom the complaint will be referred;
(F) of the results of the hospital's investigation
and the hospital's resolution with the complainant; and
(G) of HHSC's findings if an on-site audit investigation
was conducted.
(5) HHSC shall refer investigative reports of billing
by health care professionals who have provided improper, unreasonable,
or medically or clinically unnecessary treatments or billed for treatments
which were not provided to the appropriate licensing agency.
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