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Bill

HB 3845

Relating to the regulation of certain compensation, contracting, employment, and performance criteria in connection with utilization review of health benefits.

89th Legislature (2025) Introduced by Tom Oliverson

HB 3845 regulates insurance utilization review compensation and performance criteria to reduce financial incentives for treatment denials in Texas health plans.

Referred to Insurance
#civilremedies&liabilities(i0065) #insurance--health&accident(i0422)
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Bill Summary · HB 3845

Legislative bill overview

HB 3845 establishes new regulations governing how health insurance companies conduct utilization reviews—the process where insurers determine whether prescribed medical treatments are medically necessary before approving coverage. The bill specifically addresses compensation structures, contracting terms, employment arrangements, and performance metrics used by utilization review organizations and their medical reviewers.

Why is this important

Utilization reviews directly affect patient access to healthcare by determining what treatments insurers will pay for. How reviewers are compensated and evaluated can create incentives that either encourage denials of care or approval of necessary treatments. This bill attempts to align those incentives with patient welfare rather than cost-cutting alone, potentially affecting both insurance premiums and patients' ability to obtain prescribed treatments.

Potential points of contention

  • Definition of "appropriate" metrics: Determining which performance criteria incentivize correct medical decisions versus cost-containment is subjective and may lead to disputes about implementation standards
  • Cost impacts on insurers: Restrictions on denial-based compensation models could increase administrative costs, potentially raising premiums or reducing insurer profits
  • Scope and enforceability: The bill's specific requirements remain unclear from the title alone; details about which entities are covered and how violations are penalized will significantly affect real-world impact

Compiled from official sources — confirm details with the bill’s official record.

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