Arizona State Representative David Cook’s bill to hold health insurance companies accountable for honoring their contractual obligations, is winning bipartisan support.
Cook’s bill, HB2035, passed out of the House on a 57-1-1 vote and passed out of the Senate Health Committee this week on a unanimous vote.
The bill is an attempt to reform the way insurance companies reimburse hospitals.
According to the bill’s supporters, the usual lengthy appeal process, which can involve several steps, is being condensed to one single appeal that will be handled by an administrative law judge. “Currently, your first appeal is usually back to the same insurance company that denied your claim. Which is obviously going to go in favor of the insurance company almost every time.” said one supporter. The bill also will reduce, from 90 days to 45 days, the amount of time insurance companies have to certify new physicians. “When insurance companies drag this process out, it allows them to deny claims for services provided by these physicians, leaving hospitals to hold the bag. There are no shortage of horror stories that patients have and this bill hopes to dramatically increase the payment of legitimate claims made.”
Rural hospital officials, Phil Fitzgerald with the Havasu Regional Medical Center and Heath Evans of the Kingman Regional Medical Center, recently described the bill as “a beacon of hope.”
“HB2035 emerges as a beacon of hope in this scenario. It doesn’t introduce burdensome mandates but rather seeks to hold health insurance companies accountable for honoring their contractual obligations,” wrote Fitzgerald and Evans in an opinion piece in the Capitol Times. “The bill, sponsored by Rep. Cook, doesn’t ask for special treatment – it merely demands fairness, transparency, and reasonableness in the health care payment process.”
HB2035 provisions:
1. Requires a health care insurer that denies a health care services claim, in whole or in part, to provide the health care provider at the time of denial with contact information for an individual who is able to respond to questions about the denial, including a telephone number and email address.
2. Requires a health care insurer, at the request of a health care provider, to provide the following information within 15 days:
a) if a denial was based on lack of medical necessity, a detailed reason why the service was not medically necessary and the provider’s right to appeal;
b) a provider’s right to dispute the insurer’s decision, including how to file a dispute using the insurer’s internal grievance process and how to request a hearing if the grievance is unresolved; and
c) if the health care plan is not subject to DIFI regulation, a notification to the provider of the appropriate regulatory authority.
3. Requires a health care insurer, within 30 days of receiving a written grievance, to respond in writing with a decision, unless the health care provider and insurer mutually agree to a longer time period.
4. Requires a health care insurer’s decision regarding a grievance to include the:
a) date of the decision;
b) factual and legal basis for the decision;
c) health care provider’s right to request a hearing; and
d) manner in which a health care provider may request a hearing.
5. Allows a health care provider with an unresolved grievance, in whole or in part, to submit a written request for a hearing to DIFI within 30 days of receiving the health care insurer’s decision or the date on which the provider should have received the insurer’s decision
6. Requires health care insurers to receive a copy of any hearing requests submitted to DIFI.
7. Requires DIFI to request a hearing within OAH if a health care provider timely submits a request.
8. Stipulates that, if a health care provider decides to withdraw a hearing request, the provider must send a written request for withdrawal to DIFI.
9. Requires DIFI to accept a written request for withdrawal if the request is received prior to DIFI’s hearing request.
10. Requires a health care provider seeking to withdraw a hearing request to send a request to OAH if DIFI has already submitted a hearing request.
11. Stipulates that, if a party to a decision seeks further administrative review, DIFI may not be a party to the action unless it files a motion to intervene in the action.
12. Removes the ability of a health care insurer’s designee to credential providers.
13. Reduces, from 100 to 45, the number of days a health care insurer has to conclude the process of credentialing and loading an applicant’s information into the insurer’s billing system after receiving a complete credentialing application.
14. Requires health care insurers to pay claims for covered services provided to a subscriber by a participating provider who has a fully executed contract with a network plan and whose credentialing application has been approved by the insurer retroactively to the date of the provider’s complete credentialing application.