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| To enact sections 3964.01, 3964.02, 3964.05 to | 1 |
| 3964.07, 3964.10 to 3764.12, 3964.15 to 3964.17, | 2 |
| 3964.21 to 3964.24, and 5111.0210 of the Revised | 3 |
| Code to establish standards for the use of | 4 |
| physician designation systems by health care | 5 |
| insurers. | 6 |
| Section 1. That sections 3964.01, 3964.02, 3964.05, 3964.06, | 7 |
| 3964.07, 3964.10, 3964.11, 3764.12, 3964.15, 3964.16, 3964.17, | 8 |
| 3964.21, 3964.22, 3964.23, 3964.24, and 5111.0210 of the Revised | 9 |
| Code be enacted to read as follows: | 10 |
| Sec. 3964.01. As used in this chapter: | 11 |
| (A) "Health care insurer" means an entity that offers a | 12 |
| policy, contract, or plan for covering the cost of health care | 13 |
| services for individuals who are beneficiaries of or enrolled in | 14 |
| the policy, contract, or plan, including all of the following: | 15 |
| (1) A sickness and accident insurance company authorized to | 16 |
| do the business of insurance in this state; | 17 |
| (2) A health insuring corporation that holds a certificate of | 18 |
| authority under Chapter 1751. of the Revised Code; | 19 |
| (3) An entity that offers a multiple employer welfare | 20 |
| arrangement, as defined in section 1739.01 of the Revised Code; | 21 |
| (4) The state, a political subdivision, or any other | 22 |
| government entity that offers a public employee health benefit | 23 |
| plan. | 24 |
| (B) "Physician" means an individual authorized under Chapter | 25 |
| 4731. of the Revised Code to practice medicine and surgery or | 26 |
| osteopathic medicine and surgery. | 27 |
| (C) "Physician designation" means a grade, star, tier, or any | 28 |
| other rating used by a health care insurer to characterize or | 29 |
| represent the insurer's assessment or measurement of a physician's | 30 |
| cost efficiency, quality of care, or clinical performance. | 31 |
| "Physician designation" does not include either of the following: | 32 |
| (1) Information derived solely from satisfaction surveys or | 33 |
| other comments provided by individuals who are beneficiaries of or | 34 |
| enrolled in a policy, contract, or plan offered by a health care | 35 |
| insurer; | 36 |
| (2) Information for a program established by a health care | 37 |
| insurer to assist individuals with estimating a physician's | 38 |
| routine fees for providing services. | 39 |
| Sec. 3964.02. If a health care insurer operates a system for | 40 |
| making physician designations, all of the following apply with | 41 |
| respect to each physician designation that is made: | 42 |
| (A) The health care insurer shall include a quality-of-care | 43 |
| component in making the physician designation. Inclusion of the | 44 |
| quality-of-care component may be satisfied by incorporating one or | 45 |
| more practice guidelines or performance measures pursuant to | 46 |
| division (F) of this section. The resulting designation shall | 47 |
| include a clear description of the weight given to the | 48 |
| quality-of-care component in comparison to other factors used in | 49 |
| making the designation. | 50 |
| (B) The health care insurer shall include statistical | 51 |
| analyses in making the physician designation. The insurer shall | 52 |
| use statistical analyses that are accurate, valid, and reliable. | 53 |
| Where reasonably possible, the insurer shall use statistical | 54 |
| analyses that have been appropriately adjusted to reflect known | 55 |
| statistical anomalies, including factors pertaining to patient | 56 |
| population, case mix, severity of condition, comorbidities, and | 57 |
| outlier events. | 58 |
| (C) The health care insurer shall make a physician | 59 |
| designation only after completing a period of assessment of the | 60 |
| data to be used in making the designation. The insurer shall | 61 |
| update the data at appropriate intervals. | 62 |
| (D) If data from claims for payment are used in making the | 63 |
| physician designation, the health care insurer shall use accurate | 64 |
| claims data and attribute the data appropriately to the physician. | 65 |
| If reasonably available, aggregated claims data shall be used to | 66 |
| supplement the insurer's claims data. | 67 |
| (E) The health care insurer shall make the physician | 68 |
| designation in a manner that recognizes the physician's | 69 |
| responsibility for making health care decisions and the financial | 70 |
| consequences of those decisions. The financial consequences of the | 71 |
| physician's health care decisions shall be attributed to the | 72 |
| physician in a manner that is accurate and fair to the physician. | 73 |
| (F) If practice guidelines or performance measures are used | 74 |
| in making the physician designation, the health care insurer shall | 75 |
| use guidelines or measures that are evidence-based, whenever | 76 |
| possible; consensus-based, whenever possible; and pertinent to the | 77 |
| physician's area of practice, location, and patient population | 78 |
| characteristics. To the maximum extent possible, the insurer shall | 79 |
| use practice guidelines or performance measures that have been | 80 |
| established by nationally recognized health care organizations, | 81 |
| including the national quality forum, the AQA alliance, or a | 82 |
| successor organization. | 83 |
| Sec. 3964.05. Except as provided in section 3964.06 of the | 84 |
| Revised Code, a health care insurer may disclose any or all of its | 85 |
| physician designations to any member of the public, including a | 86 |
| physician, a patient or potential patient, or an individual who is | 87 |
| or may become a beneficiary of or enrolled in a health care | 88 |
| policy, contract, or plan offered by the insurer. | 89 |
| Sec. 3964.06. (A) When a health care insurer makes a | 90 |
| physician designation, including a change in a designation, the | 91 |
| insurer shall notify the physician before disclosing the | 92 |
| designation to the public. The notice shall be provided in writing | 93 |
| and shall inform the physician of both of the following: | 94 |
| (1) The process for obtaining information under sections | 95 |
| 3964.10 and 3964.11 of the Revised Code regarding the method and | 96 |
| data used in making the designation; | 97 |
| (2) The opportunity to request an appeal of the designation | 98 |
| pursuant to section 3964.15 of the Revised Code. | 99 |
| (B) After providing the written notice required under | 100 |
| division (A) of this section, the health care insurer shall not | 101 |
| disclose the physician designation until the latter of the | 102 |
| following: | 103 |
| (1) Forty-five days after providing the notice; | 104 |
| (2) Fifteen days after fulfilling any request for information | 105 |
| under section 3964.10 of the Revised Code; | 106 |
| (3) Fifteen days after fulfilling any request for information | 107 |
| under section 3964.11 of the Revised Code; | 108 |
| (4) The date the designation is in compliance with a final | 109 |
| decision made pursuant to any appeal requested under section | 110 |
| 3964.15 of the Revised Code. | 111 |
| Sec. 3964.07. (A) When a health care insurer discloses a | 112 |
| physician designation under section 3964.05 of the Revised Code, | 113 |
| the insurer shall include with the disclosure a statement | 114 |
| specifying all of the following: | 115 |
| (1) That physician designations are intended to be used only | 116 |
| as a guide in selecting a physician; | 117 |
| (2) That physician designations should not be the sole factor | 118 |
| used in selecting a physician; | 119 |
| (3) That physician designations have a risk of error; | 120 |
| (4) That individuals should discuss physician designations | 121 |
| with a physician before a selection is made. | 122 |
| (B) The statement required by this section shall accompany | 123 |
| the disclosure of the physician designation in a conspicuous | 124 |
| manner, be provided in writing, and be printed in boldface type. | 125 |
| Sec. 3964.10. (A) A request for a description of the method | 126 |
| used by a health care insurer to make a physician designation and | 127 |
| an identification of all data used in making the designation may | 128 |
| be submitted to the insurer by any of the following: | 129 |
| (1) The physician who is the subject of the designation; | 130 |
| (2) A representative of the physician who is the subject of | 131 |
| the designation; | 132 |
| (3) The superintendent of insurance. | 133 |
| (B) Not later than forty-five days after receiving a request | 134 |
| under this section, the health care insurer shall provide the | 135 |
| requested information. In providing the information, the insurer | 136 |
| is subject to all of the following: | 137 |
| (1) The description of the method used in making the | 138 |
| physician designation shall be sufficiently detailed to allow the | 139 |
| person who submitted the request to determine the effect of the | 140 |
| method on the data used in making the designation. As applicable, | 141 |
| the description shall include an explanation of the use of | 142 |
| algorithms or studies, the assessment of data, and the application | 143 |
| of practice guidelines or performance measures. | 144 |
| (2) The identification of data used in making the physician | 145 |
| designation shall be made in a manner that is reasonably | 146 |
| understandable and allows the person who submitted the request to | 147 |
| verify the data against the person's records. | 148 |
| (3) If the health care insurer has contractual obligations | 149 |
| with another person that provides for the confidentiality of | 150 |
| portions of the method or data used in making the physician | 151 |
| designation, the insurer may withhold the confidential information | 152 |
| but shall provide sufficient information to allow the person who | 153 |
| submitted the request to determine how the withheld information | 154 |
| affected the designation. | 155 |
| Sec. 3964.11. After receiving information pursuant to a | 156 |
| request submitted under section 3964.10 of the Revised Code, the | 157 |
| recipient may submit a request to the health care insurer for | 158 |
| information that discloses the complete method used by the insurer | 159 |
| to make the physician designation. | 160 |
| Not later than thirty days after receiving a request under | 161 |
| this section, the health care insurer shall provide the requested | 162 |
| information. | 163 |
| Sec. 3964.12. Neither sections 1333.61 to 1333.69 of the | 164 |
| Revised Code nor any other provision of the Revised Code | 165 |
| pertaining to trade secrets excuse a health care insurer from | 166 |
| complying with sections 3964.10 and 3964.11 of the Revised Code. | 167 |
| Sec. 3964.15. A health care insurer that operates a system | 168 |
| for making physician designations shall afford a physician who is | 169 |
| subject to the physician designation system an opportunity to | 170 |
| appeal the insurer's decision regarding the physician's | 171 |
| designation, including a decision by the insurer to change a | 172 |
| previous designation or to make no designation. In appealing the | 173 |
| decision, the physician may be assisted by a representative. | 174 |
| Sec. 3964.16. A health care insurer shall establish | 175 |
| procedures for the conduct of appeals under section 3964.15 of the | 176 |
| Revised Code. At a minimum, the procedures established by the | 177 |
| insurer shall include all of the following: | 178 |
| (A) A reasonable method for providing notice to the insurer | 179 |
| that an appeal is being sought by the physician or the physician's | 180 |
| representative; | 181 |
| (B) Consideration of any information obtained by the | 182 |
| physician or the physician's representative pursuant to section | 183 |
| 3964.10 or 3964.11 of the Revised Code; | 184 |
| (C) With respect to the data and method used to make the | 185 |
| physician designation, an opportunity for the physician or the | 186 |
| physician's representative to submit corrected data for | 187 |
| consideration and to have the appropriateness of the method | 188 |
| evaluated; | 189 |
| (D) Disclosure of the name, title, qualifications, and | 190 |
| relationship to the health care insurer of the person or persons | 191 |
| designated by the insurer to be responsible for conducting the | 192 |
| appeal proceedings and making the final decision; | 193 |
| (E) If requested by the physician or the physician's | 194 |
| representative, an opportunity to meet with the person or persons | 195 |
| responsible for conducting the appeal proceedings and making the | 196 |
| final decision, either by meeting in person at a location | 197 |
| reasonably convenient to the physician or the physician's | 198 |
| representative or by teleconference. | 199 |
| (F) If requested by the physician or the physician's | 200 |
| representative, consideration of an explanation of the designation | 201 |
| decision by the person or persons identified by the health care | 202 |
| insurer as being responsible for the designation decision; | 203 |
| (G) Completion of the appeals process not later than | 204 |
| forty-five days after the physician or physician's representative | 205 |
| provides notice that an appeal is being sought, unless another | 206 |
| time is agreed to by the physician or the physician's | 207 |
| representative; | 208 |
| (H) Issuance of a written final decision that states the | 209 |
| reasons for upholding, modifying, or rejecting the appeal. | 210 |
| Sec. 3964.17. If a physician designation subject to an appeal | 211 |
| under section 3964.15 of the Revised Code was disclosed to the | 212 |
| public before the appeal was made and the final decision regarding | 213 |
| the appeal is in favor of the physician, the health care insurer | 214 |
| shall modify its designation of the physician in accordance with | 215 |
| the final decision. The health care insurer shall make the | 216 |
| necessary changes to the designation not later than thirty days | 217 |
| after the final decision regarding the appeal is made. | 218 |
| Sec. 3964.21. A health care insurer shall not fail to comply | 219 |
| with sections 3964.02 to 3964.17 of the Revised Code. | 220 |
| Sec. 3964.22. In the case of a health care insurer that is | 221 |
| regulated by the department of insurance, a series of violations | 222 |
| of section 3964.21 of the Revised Code that, taken together, | 223 |
| constitutes a pattern or practice of violating that section shall | 224 |
| be considered an unfair and deceptive act or practice in the | 225 |
| business of insurance under sections 3901.19 to 3901.26 of the | 226 |
| Revised Code. | 227 |
| Sec. 3964.23. A physician who is adversely affected by a | 228 |
| violation of section 3964.21 of the Revised Code has a cause of | 229 |
| action against the health care insurer and may seek a declaratory | 230 |
| judgment, an injunction, or other appropriate relief. | 231 |
| Sec. 3964.24. Any provision of a contractual arrangement | 232 |
| between a health care insurer and physician that limits any of the | 233 |
| physician's rights granted by this chapter or that is otherwise | 234 |
| contrary to the provisions of this chapter is unenforceable. | 235 |
| Sec. 5111.0210. Chapter 3964. of the Revised Code applies to | 236 |
| the medicaid program in the same manner that the chapter applies | 237 |
| to a health care insurer, as defined in section 3964.01 of the | 238 |
| Revised Code. | 239 |