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S. B. No. 98 As IntroducedAs Introduced
128th General Assembly | Regular Session | 2009-2010 |
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A BILL
To enact sections 3964.01, 3964.02, 3964.05 to
3964.07, 3964.10 to 3964.12, 3964.15 to 3964.17,
3964.21 to 3964.24, and 5111.0210 of the Revised
Code to establish standards for physician
designations by health care
insurers.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 3964.01, 3964.02, 3964.05, 3964.06,
3964.07, 3964.10, 3964.11, 3964.12, 3964.15, 3964.16, 3964.17,
3964.21, 3964.22, 3964.23, 3964.24, and 5111.0210 of the Revised
Code be enacted to read as follows:
Sec. 3964.01. As used in this chapter:
(A) "Health care insurer" means an entity that offers a
policy, contract, or plan for covering the cost of health care
services for individuals who are beneficiaries of or enrolled in
the policy, contract, or plan, to the extent that the entity and
the policy, contract, or plan are subject to the laws of this
state. "Health care entity" includes all of the following:
(1) A sickness and accident insurance company authorized to
do the business of insurance in this state;
(2) A health insuring corporation that holds a certificate of
authority issued under Chapter 1751. of the Revised Code;
(3) An entity that offers a multiple employer welfare
arrangement, as defined in section 1739.01 of the Revised Code;
(4) The state, a political subdivision, or any other
government entity that offers a public employee health benefit
plan.
(B) "Physician" means an individual authorized under Chapter
4731. of the Revised Code to practice medicine and surgery or
osteopathic medicine and surgery.
(C) "Physician designation" means a grade, star, tier, or any
other rating used by a health care insurer to characterize or
represent the insurer's assessment or measurement of a physician's
cost efficiency, quality of care, or clinical performance.
"Physician designation" does not include either of the following:
(1) Information derived solely from satisfaction surveys or
other comments provided by individuals who are beneficiaries of or
enrolled in a policy, contract, or plan offered by a health care
insurer;
(2) Information for a program established by a health care
insurer to assist individuals with estimating a physician's
routine fees for providing services.
Sec. 3964.02. If a health care insurer operates a system for
making physician designations, all of the following apply with
respect to each physician designation that is made:
(A) The health care insurer shall include a quality-of-care
component in making the physician designation. Inclusion of the
quality-of-care component may be satisfied by incorporating one or
more practice guidelines or performance measures pursuant to
division (F) of this section. The resulting designation shall
include a clear description of the weight given to the
quality-of-care component in comparison to other factors used in
making the designation.
(B) The health care insurer shall use statistical
analyses
in making the physician designation. The insurer shall
use
statistical analyses that are accurate, valid, and reliable.
Where reasonably possible, the insurer shall use statistical
analyses that have been appropriately adjusted to reflect known
statistical anomalies, including factors pertaining to patient
population, case mix, severity of condition, comorbidities, and
outlier events.
(C) The health care insurer shall make a physician
designation only after completing a period of assessment of data
pertinent to the designation. The insurer shall
update the data
at appropriate intervals.
(D) If data from claims for payment are used in making the
physician designation, the health care insurer shall use accurate
claims data and attribute the data appropriately to the physician.
If reasonably available, aggregated claims data shall be used to
supplement the insurer's claims data.
(E) The health care insurer shall make the physician
designation in a manner that recognizes the physician's
responsibility for making health care decisions and the financial
consequences of those decisions. The financial consequences of the
physician's health care decisions shall be attributed to the
physician in a manner that is accurate and fair to the physician.
(F) If practice guidelines or performance measures are used
in making the physician designation, the health care insurer shall
use guidelines or measures that are evidence-based, whenever
possible; consensus-based, whenever possible; and pertinent to the
physician's area of practice, location, and patient-population
characteristics. To the maximum extent possible, the insurer shall
use practice guidelines or performance measures that have been
established by nationally recognized health care organizations,
including the national quality forum or its successor, or the AQA
alliance or its
successor.
Sec. 3964.05. Except as provided in section 3964.06 of the
Revised Code, a health care insurer may disclose any or all of its
physician designations to any of the following:
(B) A patient or potential patient;
(C) An individual who is or may become a beneficiary of or
enrolled in a health care policy, contract, or plan offered by the
insurer;
(D) Any other individual.
Sec. 3964.06. (A) When a health care insurer makes a
physician designation, including a change in a designation, the
insurer shall notify the physician before disclosing the
designation to the public. The notice shall be provided in writing
and shall inform the physician of both of the following:
(1) The process by which the physician may request
information under sections
3964.10 and 3964.11 of the Revised
Code regarding the method
and
data used in making the
designation;
(2) The opportunity to request an appeal of the designation
pursuant to section 3964.15 of the Revised Code.
(B) After providing the written notice required under
division (A) of this section, the health care insurer shall not
disclose the physician designation until the latest occurring of
the
following:
(1) Forty-five days after providing the notice;
(2) Fifteen days after fulfilling any request for information
under section 3964.10 of the Revised Code;
(3) Fifteen days after fulfilling any request for information
under section 3964.11 of the Revised Code;
(4) The date that the designation is in compliance with a
final
decision made pursuant to an appeal requested under section
3964.15 of the Revised Code.
Sec. 3964.07. (A) When a health care insurer discloses a
physician designation under section 3964.05 of the Revised Code,
the insurer shall include with the disclosure a statement
specifying all of the following:
(1) That physician designations are intended to be used only
as a guide in selecting a physician;
(2) That physician designations should not be the sole factor
used in selecting a physician;
(3) That physician designations have a risk of error;
(4) That individuals should discuss physician designations
with a physician before a selection is made.
(B) The statement required by this section shall accompany
the disclosure of the physician designation in a conspicuous
manner, shall be provided in writing, and shall be printed in
boldface type.
Sec. 3964.10. (A) Any of the following may submit a request
to a health care insurer asking that the insurer provide a
description of the method used by the insurer in making a
physician designation and, for a particular designation, a
description
of all data used in making the designation:
(1) The physician who is the subject of the designation;
(2) A representative of the physician who is the subject of
the designation;
(3) The superintendent of insurance.
(B) Not later than forty-five days after receiving a request
under this section, the health care insurer shall provide the
requested information to the person who submitted the request. In
providing the information, the insurer
is subject to all of the
following:
(1) The description of the method used in making the
physician designation shall be sufficiently detailed to allow the
person who submitted the request to determine the effect of the
method on the data used in making the designation. As applicable,
the description shall include an explanation of the use of
algorithms or studies, the assessment of data, and the application
of practice guidelines or performance measures.
(2) The description of the data used in making the physician
designation shall be made in a manner that is reasonably
understandable and allows the person who submitted the request to
verify the data against the person's records.
(3) If the health care insurer has a contract with another
person that prevents the insurer from disclosing all or part of
the data used in making the physician
designation, the insurer
may withhold the data
but shall provide sufficient information to
allow the person who
submitted the request to determine how the
withheld data
affected the designation.
Sec. 3964.11. After receiving a description of a health care
insurer's method used in making a physician designation pursuant
to a
request submitted under section 3964.10 of the Revised Code,
the
recipient may submit a request to the insurer asking that the
insurer provide the complete method used by the insurer
in making
the physician designation.
Not later than thirty days after receiving a request under
this section, the health care insurer shall provide the requested
information to the person who submitted the request.
Sec. 3964.12. Neither sections 1333.61 to 1333.69 of the
Revised Code nor any other provision of the Revised Code
pertaining to trade secrets excuses a health care insurer from
complying with sections 3964.10 and 3964.11 of the Revised Code.
Sec. 3964.15. A health care insurer that operates a system
for making physician designations shall afford a physician who is
subject to the physician designation system an opportunity to
appeal the insurer's decision regarding the physician's
designation, including a decision by the insurer to change a
previous designation or to make no designation. In appealing the
decision, the physician may be assisted by a representative.
Sec. 3964.16. A health care insurer shall establish
procedures for the conduct of appeals under section 3964.15 of the
Revised Code. At a minimum, the procedures established by the
insurer shall include all of the following:
(A) A reasonable method for a physician or a physician's
representative to provide notice to the insurer
that an appeal is
being sought;
(B) Consideration of any information obtained by the
physician or the physician's representative pursuant to section
3964.10 or 3964.11 of the Revised Code;
(C) If requested by the physician or the physician's
representative, consideration of an explanation of the decision
regarding the physician designation, with the explanation supplied
by the person or persons identified by the health care
insurer as
being responsible for making the designation decision;
(D) With respect to the data and method used by the insurer
to make the
physician designation decision, an opportunity for
the physician or the
physician's representative to submit to the
insurer corrected data for the insurer's consideration and to have
the appropriateness of the method
evaluated by the insurer;
(E) Disclosure of the name, title, qualifications, and
relationship to the health care insurer of the person or persons
designated by the insurer as responsible for conducting the
appeal proceedings and making the final decision;
(F) If requested by the physician or the physician's
representative, an opportunity to meet with the person or persons
responsible for conducting the appeal proceedings and making the
final decision, either by meeting in person at a location
reasonably convenient to the physician or the physician's
representative or by teleconference.
(G) Completion of the appeals process not later than
forty-five days after the physician or physician's representative
provides notice that an appeal is being sought, unless another
time is agreed to by the physician or the physician's
representative;
(H) Issuance of a written final decision that states the
reasons for upholding, modifying, or rejecting the physician
designation decision subject to the appeal.
Sec. 3964.17. If the final decision regarding an appeal
under section 3964.15 of the Revised Code is in favor of the
physician, the health care insurer
shall modify its designation
of the physician in accordance with
the final decision. In
modifying the designation, the insurer is subject to both of the
following:
(A) If the designation was disclosed to the public before the
appeal was made, the
insurer shall make the
necessary changes to
the designation not later than thirty days
after the final
decision regarding the appeal is made.
(B) If the designation was not disclosed to the public before
the appeal was made, the insurer shall make the necessary changes
to the designation before the designation is disclosed to the
public.
Sec. 3964.21. A health care insurer shall not fail to comply
with sections 3964.02 to 3964.17 of the Revised Code.
Sec. 3964.22. In the case of a health care insurer that is
regulated by the department of insurance, a series of violations
of
section 3964.21 of the Revised Code that, taken together,
constitutes a pattern or practice of violating that section shall
be considered an unfair and deceptive act or practice in the
business of insurance under sections 3901.19 to 3901.26 of the
Revised Code.
Sec. 3964.23. A physician who is adversely affected by a
violation of section 3964.21 of the Revised Code has a cause of
action against the health care insurer and may seek a declaratory
judgment, an injunction, or other appropriate relief.
Sec. 3964.24. Any provision of a contractual arrangement
between a health care insurer and physician that limits any of the
physician's rights granted by this chapter or that is otherwise
contrary to the provisions of this chapter is unenforceable.
Sec. 5111.0210. Chapter 3964. of the Revised Code applies to
the medicaid program in the same manner that the chapter applies
to a health care insurer, as defined in section 3964.01 of the
Revised Code.
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