No. HB 1015
Filed under Insurance.
Insurance Claims Payments to Health Care Providers; Prohibits payment adjudicators from downcoding health care services under certain circumstances; requires health insurers to ensure that their downcoding policies are updated & to ensure compliance with specified provisions on downcoding; authorizes investigations & actions against noncompliance; provides certain presumption in favor of physicians' determination regarding patients' diagnoses & service orders; provides calculations of interests on health insurers' nonpayment & underpayment due to downcoding; provides causes of action for health care providers; prohibits utilization review entities from implementing new requirements, restrictions, & changes on prior authorizations under certain circumstances; provides requirements for adverse determinations made by such entities on health care providers' claims; revises requirements & timeframes for responses from health insurers & HMOs to submitted claims.
Plain English Summary
AI-GENERATEDInsurers and their payment processors can no longer downcode a service ordered by an in-network provider unless their contract allows it, and even then must review the medical record and let the provider contest it within 15 days.
Utilization review entities must post any new prior-authorization requirement 60 days before enforcing it, and once care is delivered within 45 business days of an approval, the payment obligation becomes almost impossible to undo.
Health insurers and HMOs must pay or deny claims faster than before, owe 15 percent interest on the full amount of a late payment rather than just the shortfall, and must claim any overpayment within 18 months instead of 30.
Insureds who report a service they never received no longer get a share of the refund, and insurers can no longer retroactively deny a claim for eligibility problems more than 90 days after paying it.
AIPayment adjudicators can no longer downcode -- pay a lower-value code than the one billed -- for a service ordered by an in-network provider unless the insurer's own participation agreement with that provider expressly allows it.
AIWhen a licensed physician orders a service, the law presumes the physician's diagnosis and service order are correct, and an insurer must verify any coding error directly with that physician before downcoding on that basis.
AIA utilization review entity cannot roll out a new prior-authorization requirement, restriction, or change unless it has been posted publicly and affected providers notified in writing at least 60 days beforehand, with the contract amendment already in writing.
AIOnce a provider gets prior authorization and delivers the care within 45 business days, the authorization becomes a conclusive determination of medical necessity, and the insurer owes payment at the contracted rate with only four narrow exceptions.
AIA claim can no longer be denied on medical-necessity grounds by just any reviewer -- the physician making that call must share the treating physician's specialty, have five years of relevant experience, and have no financial stake in the outcome.
AIOnce a provider grants an insurer or HMO access to a patient's electronic medical record, the provider is deemed to have supplied everything needed, and any claim of missing information can no longer be used to deny, reduce, or delay payment.
AIAn insurer or HMO must now present any overpayment claim to a provider within 18 months of paying the original claim, down from 30 months, and generally cannot withhold payment on a provider's other, unrelated claims to satisfy the alleged overpayment.
AIThe interest rate on a late claim rises from 12 to 15 percent a year, and when a tribunal later finds a claim should have been paid in full, that 15 percent runs on the entire amount owed rather than merely the gap between what was paid and what was owed.