Public Policy Priorities

2017 - Promoting Health Plan (HP) Reform to Benefit Patients and Physicians

Overview: The Deteriorating Practice Environment and Patient Hurdles
Mergers put all power in hands of very few HPs. No market competition because of the concentration of power.  Physicians are forced to accept contracts of adhesion from HPs. (A contract of adhesion is a take-it-or-leave-it proposition entered into between unequal bargaining partners.)

Patients are losing their physicians due to narrowing networks with increasing physician deselections from networks without a clear explanation or appeal right as HPs chase lowest cost point.

No transparency by HPs regarding payment for OON charges, with a pattern of HPs using fraudulent databases to set rates—no trust of HPs due to history of fraud- must use an independent database.

Prior authorization and payment nightmares for physicians and their patients.

Scant regulatory enforcement biased in favor of HPs.

Issue #1 OON and Surprise Bills

  • Establishes a fair and transparent solution to the OON Network “surprise bills” issue.
  • Puts a shared and fair responsibility for notifying patients on facility, OON provider and health plan.
  • Protects consumer from balance billing.
  • Establishes a fair reimbursement rate for providers.
  • Sets up a due process appeal for OON physicians to challenge “unfair reimbursement rates.”

Issue #2 DOI Complaints and Dispute Resolution

  • Require DOI Commissioner to investigate and resolve complaints from physicians regarding claim mishandling and inappropriate denials.
  • Includes provider complaints in the annual report to the legislators.
  • Authorizes the Commissioner to financially penalize a HP for a pattern of abuse.

Issue #3 Selection-Deselection: Notification of Patients and Providers, Transparent Standards, Appeal Rights

  • Requires transparency and fairness in HPs network construction (selection/deselection process) and in development of tiered networks.
  • Requires HPs to communicate to physicians the standards for selection/deselection and tiering of networks.
  • Products identified as value, high performing or quality must have quality as the main criteria and not cost for selection/deselection.
  • Criteria should not discriminate against physicians who are serving or treating high risk populations, or who are located in geographic areas that may cause higher than average costs.
  • Criteria should not discriminate against providers because they treat populations with chronic conditions that may cause a higher than average claims, losses or health care services utilization.
  • Creates an appeal right for providers who have been excluded or deselected from participating with a network.

Issue #4 Mergers: Transparency and Independent Investigations
For merger approvals: Requires foreign HPs to publicly disclose the Form E (HPs anticompetitive analysis). Requires the DOI to solicit public input concerning the anticompetitive effects of the proposed merger.

Issue #5 Protection from Retaliation
Requires Commissioner to impose penalties for HPs engaging in patterns of abuse in retaliation for physicians informing regulators or legislators about the problems and concerns they face when dealing with health plans.
Issue #6 Making Telehealth Work

Some HPs are implementing the 2015 law, that was intended to foster the appropriate use of telehealth throughout the state, by requiring physicians to use each HPs different telehealth vendor. Physicians are being required to contract with numerous vendors – raising cost of health care. This was never the intent of the 2015 law.  This bill seeks to clarify the intent of the 2015 law.