SB 765

Abstract

Health insurance; provider contracts; business practices;penalties. Prohibits a carrier from unilaterally amending a providercontract or any material provision, addenda, schedule, exhibit, or policy thereto,as it relates to any material provision that was agreed to or accepted by theprovider in the previous 12-month period. The measure requires such anamendment to be agreed to by the provider in a signed written amendment to theprovider contract. The measure defines a material provision of a providercontract as any policy manual, coverage guideline, edit, multiple procedurelogic, or audit procedure that (i) decreases the provider's payment orcompensation, (ii) limits an enrollee's access to covered services under hishealth plan, or (iii) changes the administrative procedures applicable to aprovider contract in a way that may reasonably be expected to significantlyincrease the provider's administrative expense. The measure requires carriers topermit a provider to determine the carrier's policies regarding the use ofedits or multiple procedure logic. The measure requires carriers to provide,for each health plan in which the provider participates or is proposed toparticipate, a complete fee schedule for all health care services includedunder the provider contract with the provider in writing and to make themavailable in machine-readable electronic format. The measure requires carriersto permit a provider a minimum of one year from the date a health care serviceis rendered to submit a claim for payment. The measure also (a) requires theState Corporation Commission to assist providers and to examine and investigateprovider complaints and inquiries relating to an alleged or suspected failure bya carrier to comply with required minimum fair business standards, (b) requiresthe Commission to provide a determination of whether a carrier has failed tocomply with these standards within 60 days of receipt of a provider's complaintor inquiry, (c) authorizes the Commission to determine whether a person'spractices comply with these standards, (d) subjects a person that refuses orfails to provide information in a timely manner to the Commission toenforcement and penalty provisions, and (e) authorizes the Commission to imposepenalties or issue a cease and desist order to a carrier that fails to complywith these standards.