AN ACT CONCERNING HEALTH CARE PROVIDER CONTRACTS.

This bill requires each contracting health organization (i. e. , a managed care organization or preferred provider network) to include with each contract it offers a specified provider:

1. access to the organization's current procedural terminology (CPT) codes and Healthcare Common Procedure Coding System fee schedules that apply to the provider's specialty (see COMMENT);

2. the name of, and contact information for, the medical director responsible for internal appeals;

3. a description of the procedures used to respond to a provider's inquiries; and

4. access to the organization's policies and guidelines that directly or indirectly impact patients' rights or providers' payments, duties, requirements, or appeals.

It defines “provider” as a physician, surgeon, chiropractor, podiatrist, nurse practitioner, and optometrist. However, nurse practitioners are licensed as and called advanced practice registered nurses (APRNs) in Connecticut. The bill does not define Healthcare Common Procedure Coding fee schedule.

The bill prohibits an organization from making, more than once a year, unilateral changes that directly or indirectly affect patients' rights or providers' payments, duties, requirements, or appeals, in a (1) provider contract; (2) medical payment policy, including payment method; or (3) administrative policy. It requires the organization to make any such changes simultaneously.

The bill prohibits an organization, more than one year after receiving a “clean claim,” from canceling, denying, or demanding a refund of payment for an authorized service paid in error because of an administrative or eligibility mistake. (The law considers a claim “clean” if it is submitted with all information required by law (CGS § 38a-477)). (It is unclear if this prohibition applies to all claims subject to the prompt payment law (see BACKGROUND) or only those a physician, surgeon, chiropractor, podiatrist, APRN, or optometrist files. )

If an organization returns a claim to a provider because it determined a different payor is the appropriate one to pay the claim, the bill allows the provider up to one year from when the claim is returned to file it with the correct payor. (Contracts between an organization and a provider usually include the amount of time a provider has to file a claim with a payor after rendering services to a patient. The bill, therefore, may impact such a contractual provision. )

Access to CPT Codes (CGS § 38a-479). The law requires each contracting health organization to have a process in place through which a contracted physician, physician group, or physician organization may confidentially view what the organization pays for the (1) 50 CPT codes the physician or group most commonly performs and (2) CPT codes the physician or group bills, or intends to bill, as long as they are within the physician's specialty or subspecialty. The law applies with respect to a physician, physician group, or physician organization whose services the organization reimburses on a fee-for-service basis per CPT code. For this law, “physician” includes a physician, surgeon, chiropractor, podiatrist, psychologist, and optometrist.

By law, the organization must present the fee information digitally or electronically. The law makes the fee information proprietary and confidential. It permits the organization to impose penalties, including termination from its provider network, for unauthorized disclosure.

Prompt Claim Payment (CGS § 38a-816(15)). By law, an insurer or other entity must pay a clean claim within 45 days of receiving it if. If a claim contains a deficiency, the entity must send written notice to the claimant or health care provider, as the case may be, of all alleged deficiencies within 30 days of receiving the claim. The entity must process the claim within 30 days of receiving the corrected claim. The entity must add 15% interest if payment is late.

In this case, the law defines “health care provider” as a physician, surgeon, chiropractor, naturopath, podiatrist, athletic trainer, physical therapist, occupational therapist, alcohol and drug counselor, radiologist, midwife, nurse, nurse's aide, dentist, dental hygienist, optometrist, optician, respiratory care practitioner, perfusionist, pharmacist, psychologist, marital and family therapist, clinical social worker, professional counselor, massage therapist, dietician-nutritionist, acupuncturist, emergency medical service technician (EMT), and licensed health care institution. Licensed health care institution includes a hospital; residential care home; health care facility for the handicapped; nursing home; rest home; home health care agency; homemaker-home health aide agency; mental health facility; substance abuse treatment facility; student infirmary; an EMT organization; a facility providing services for the prevention, diagnosis, and treatment of human health conditions; and a Medicaid-certified residential facility for the mentally retarded.

It is unclear how this bill, with respect to CPT codes, differs from existing law that requires organizations to give certain providers access to CPT codes, except the bill appears to include APRNs and exclude psychologists.

Yea

Nay

(03/10/2009)