AN ACT CONCERNING HEALTH CARE PROVIDER CONTRACTS.

This bill broadens the type of fee information a contracting health organization (i. e. , a managed care organization or preferred provider network) must give to health care providers with whom they contract. It also requires the organization to include with each contract it offers a specified provider Internet, electronic, or digital access to policies and procedures regarding payments to providers, providers' duties and requirements under the participating provider contract, inquiries and appeals from providers, contact information, and a description of the rights of a provider, enrollee and enrollee's dependents with respect to an appeal.

As under current law, right of access to the fees applies only to a provider of services reimbursed using current procedural codes and fee information is proprietary and confidential. The procedure adopted may penalize the unauthorized distribution of the information, including possible termination of the participating provider contract.

The bill prohibits contracting health organizations from making material changes to a provider's fee schedule except as the bill specifies. Specifically, the bill allows a contracting health care organization to make changes:

1. once a year if it gives providers at least 90 days' advance notice by mail, electronic mail, or fax of the changes and

2. at any time if it gives providers at least 30 days' advance notice by mail, electronic mail, or fax of any changes that are based on certain circumstances the bill specifies, such as (a) to comply with changes to national best practice protocols made by the National Quality Forum or other national accrediting or standard-setting organization, or (b) to be consistent with changes made in Medicare pertaining to billing or medical management practices.

The bill prohibits a contracting health organization from canceling, denying, or demanding the return of full or partial payment for an authorized covered service due to administrative or eligibility error, more than 18 months after the date of the receipt of a clean claim, except under certain circumstances. It establishes certain procedures that must be followed.

*Senate Amendment “A” expands the definition of “provider” and sets new requirements and procedures regarding cancelling, denying, or demanding payment for authorized covered services.

EFFECTIVE DATE: January 1, 2010, except the provisions relating to material changes to fee schedules and cancellation of authorized covered services, which are effective July 1, 2010.

Under current law, contracting health organizations must implement procedures to permit a physician, physician group, or physician organization to contract with a health organization to view on a confidential basis in a digital format, the 50 current procedural terminology codes most commonly performed by the physician, group, or organization. Current law applies to physicians or surgeons, chiropractors, podiatrists, psychologists, and optometrists.

The bill instead requires the organization to include with each contract it offers a specified provider Internet, electronic, or digital access to the contracting health organization's fees for the current procedural terminology (CPT) and the Health Care Procedure Coding System (HCPCS) codes applicable to or requested by such provider for other services for which such provider actually bills or intends to bill the contracting health organization, provided such codes are within the provider's specialty or subspecialty. It defines “provider” as a physician, surgeon, chiropractor, podiatrist, psychologist, optometrist, natureopath or advanced practice registered nurse licensed in this state or a group or organization of such individuals, who has entered into or renews a participating provider contract with a contracting health organization to render services to such organization's enrollees and enrollee's dependents. The bill does not define Healthcare Common Procedure Coding fee schedule.

1. the organization has a documented basis to believe that the claim was fraudulently submitted by such provider;

2. the provider did not bill appropriately for the claim based on the documentation or evidence of what medical service was actually provided;

3. the organization already paid the provider for the claim;

4. the organization paid a claim that should have been or was paid by a federal or state program; or

5. the provider received payment from a different insurer, payor, or administrator through coordination of benefits or subrogation, or due to coverage under an automobile insurance or workers' compensation policy.

The bill gives a provider that receives a payment from another source one year after the date of the cancellation, denial, or return of full or partial payment to resubmit an adjusted secondary payor claim with the organization on a secondary payor basis, regardless of the organization's timely filing requirements.

Procedure An Organization Must Follow Regarding Cancellation, Denial, or Return of Payment

The bill requires an organization to give at least 30 days' advance notice to a provider by mail, electronic mail, or fax of the organization's cancellation, denial, or demand for the return of a payment.

The notice for a demand for the return of payment must disclose to the provider (1) the amount demanded to be returned, (2) the claim that is the subject of the demand, and (3) the basis on which the return is being demanded.

The bill allows a provider to appeal a cancellation, denial, or demand in accordance with the procedures provided by such organization within 30 days after it receives notice of it. The bill requires that any demand for the return of payment be stayed during the appeal.

If there is no appeal or an appeal is denied, the bill allows a provider to resubmit an adjusted claim, if applicable, to the organization, within 30 days after receiving notice of the cancellation or denial. If a return of payment was demanded the claim may not be resubmitted.

The bill gives a provider one year after the date of the written notice to identify any other appropriate insurance coverage applicable on the date of service and to file a claim with such insurer, health care center, or other issuing entity, regardless of such insurer's, health care center's or other issuing entity's timely filing requirements.

The bill specifies that a law establishing required provisions in every contract between health care centers and participating providers applies to a participating provider contract issued by a health care center (see CGS § 38a-193(c)). (see BACKGROUND – Required Contract Provisions).

The bill prohibits contracting health organizations from making material changes to a provider's fee schedule except as follows:

A contracting health care organization may make changes once a year if it gives providers at least 90 days' advance notice by mail, electronic mail, or fax of the changes. Upon receipt of such notice, a provider may terminate the participating provider contract with at least 60 days' advance written notice to the contracting health organization.

The bill also allows a contracting health care organization to make changes at any time if it gives providers at least 30 days' advance notice by mail, electronic mail, or facsimile of any changes:

1. to comply with requirements of federal or state law, regulation or policy; if the federal or state law, regulation, or policy takes effect in fewer than 30 days, the organization must give providers as much notice as possible;

2. to comply with changes to the medical data code sets set forth in federal regulations (45 CFR 162. 1002);

3. to comply with changes to national best practice protocols made by the National Quality Forum or other national accrediting or standard-setting organization based on peer-reviewed medical literature generally recognized by the relevant medical community or the results of clinical trials generally recognized and accepted by the relevant medical community;

4. consistent with changes made in Medicare pertaining to billing or medical management practices, as long as any such changes are applied to relevant participating provider contracts where such changes pertain to the same specialty or payment methodology;

5. if a drug, treatment, procedure, or device is identified as no longer safe and effective by the federal Food and Drug Administration (FDA) or by peer-reviewed medical literature generally recognized by the relevant medical community;

6. to address payment or reimbursement for a new drug, treatment, procedure, or device that becomes available and is determined to be safe and effective by the FDA or by peer-reviewed medical literature generally recognized by the relevant medical community; or

7. as mutually agreed to by the contracting health organization and the provider.

The law (CGS § 38a-193(c)) requires that every contract between a health care center and a participating provider of health care services be in writing and contain the five specific provisions or variations approved by the commissioner.

If the participating provider contract has not been reduced to writing as required by law or does not have the provisions specified above, the participating provider may not collect or attempt to collect from the subscriber or enrollee sums owed by the health care center (CGS 38a-193 (c)).