Bill Text: MN HF122 | 2011-2012 | 87th Legislature | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Dental provider contracts and provider audits regulated.
Sponsorship: Bipartisan Bill
Status: (Introduced - Dead) 2011-05-18 - HF indefinitely postponed [HF122 Detail]
Download: Minnesota-2011-HF122-Introduced.html
Bill Title: Dental provider contracts and provider audits regulated.
Sponsorship: Bipartisan Bill
Status: (Introduced - Dead) 2011-05-18 - HF indefinitely postponed [HF122 Detail]
Download: Minnesota-2011-HF122-Introduced.html
1.2relating to insurance; regulating dental plan contracts and provider audits;
1.3amending Minnesota Statutes 2010, sections 62Q.76, by adding a subdivision;
1.462Q.78, by adding subdivisions.
1.5BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.6 Section 1. Minnesota Statutes 2010, section 62Q.76, is amended by adding a
1.7subdivision to read:
1.8 Subd. 8. Dental plan contract. "Dental plan contract" means a written agreement
1.9between a dentist or dental clinic and dental organization to provide dental care services.
1.10 Sec. 2. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.11to read:
1.12 Subd. 4. Dental plan contract period. A dental plan contract between a dental
1.13organization and a dentist or dental clinic may not exceed three years. A contract that
1.14is altered or amended by a dental organization within the three-year period may be
1.15substituted for a current contract but is not effective without the written consent of a
1.16dentist or dental clinic. The dentist must receive a copy of the proposed contract for
1.17renewal along with a disclosure by the dental organization of all material changes in terms
1.18of the contract or methods of reimbursement from the previous contract.
1.19 Sec. 3. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.20to read:
1.21 Subd. 5. Contract amendment. An amendment or change in terms of an existing
1.22contract between a dental organization and a dentist must be disclosed to the dentist at
2.1least 120 days before the effective date of the proposed change. A change to a provider's
2.2fee schedule is not an amendment or change in terms for purposes of this section. A
2.3dental organization may not alter or amend a dental plan contract, or impose an additional
2.4contractual obligation on a dentist or dental clinic, unless the dental organization complies
2.5with the requirements of this subdivision.
2.6 Sec. 4. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
2.7to read:
2.8 Subd. 6. Provider audits. (a) A dental organization is prohibited from recovering
2.9payments or otherwise withholding payments from a provider.
2.10(b) Notwithstanding paragraph (a), a dental organization may recover payments or
2.11withhold payments from a provider after an audit or investigation where the following
2.12circumstances are met:
2.13(1) the dental organization has conducted an audit or investigation of the provider's
2.14actual patient records and claims submissions, reviewed all relevant information and
2.15documentation, and made verified findings following the audit or investigation;
2.16(2) looks back no more than two years from the date the audit or investigation
2.17results are given to the provider; and
2.18(3) the payments or withholding amount do not rely, in any way, on mathematical
2.19extrapolation or other statistical modeling.
2.20(c) If a dental organization conducts a provider audit, the dental organization must
2.21use a licensed Minnesota dentist, who continues to practice chair-side and whose license
2.22is in good standing, to review the charts.
2.23(d) If a dental organization undertakes a provider audit, as referenced in this
2.24subdivision, and determines that payments have been made to a provider for a noncovered
2.25service, the dental organization must issue new explanation of benefit forms advising
2.26patients that they may be responsible for the full amount of the noncovered service.
2.27(e) Payments recovered by a dental organization as a result of a provider audit must
2.28be returned to the entity that sponsored the plan.
2.29(f) As part of any provider audit process, a dental organization shall:
2.30(1) provide a written explanation to the provider of the reason for the audit and the
2.31process the dental organization intends to use to audit the patient charts, as well as a
2.32written explanation of the processes available to the provider once the dental organization
2.33completes its review of the audited patient records;
3.1(2) allow the provider at least 120 days from the date that the provider receives the
3.2verified audit or investigation findings to review, meet, and negotiate a potential informal
3.3resolution to the audit or investigation; and
3.4(3) not be allowed to assess or otherwise require the provider to reimburse the dental
3.5organization for its internal administrative costs, external consultant expenses, attorney
3.6fees, or other costs incurred in conjunction with any audit or investigation.
3.7(g) For the purpose of this section, fraud means an intentional deception
3.8or misrepresentation a dentist or dental clinic makes knowing the deception or
3.9misrepresentation could result in an unauthorized benefit or reimbursement. Abuse
3.10means an incident or practice of a dentist or dental clinic that is inconsistent with
3.11accepted business or financial practices and which results in unnecessary cost to a dental
3.12organization.
3.13 Sec. 5. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
3.14to read:
3.15 Subd. 7. Payment for covered services. (a) Notwithstanding any other provisions
3.16of law, no dental plan or dental provider agreement of a dental organization contracting
3.17for the provision of dental care services may require, directly or indirectly, that a dentist
3.18who is a participating provider provide services to an enrolled participant at a fee set by,
3.19or at a fee subject to the approval of, the dental plan or dental organization, unless the
3.20dental services are covered services.
3.21(b) A health care service contractor or other person providing third-party
3.22administrator services shall not make available any providers in its dentist network to a
3.23plan that sets dental fees for any services except covered services.
3.24(c) For purposes of this section, "covered services" means dental care services for
3.25which a reimbursement is available under an enrollee's plan contract.
3.26 Sec. 6. EFFECTIVE DATE.
3.27Sections 1 to 5 are effective August 1, 2011, and apply to dental plans and provider
3.28agreements entered into or renewed on or after that date.
1.3amending Minnesota Statutes 2010, sections 62Q.76, by adding a subdivision;
1.462Q.78, by adding subdivisions.
1.5BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.6 Section 1. Minnesota Statutes 2010, section 62Q.76, is amended by adding a
1.7subdivision to read:
1.8 Subd. 8. Dental plan contract. "Dental plan contract" means a written agreement
1.9between a dentist or dental clinic and dental organization to provide dental care services.
1.10 Sec. 2. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.11to read:
1.12 Subd. 4. Dental plan contract period. A dental plan contract between a dental
1.13organization and a dentist or dental clinic may not exceed three years. A contract that
1.14is altered or amended by a dental organization within the three-year period may be
1.15substituted for a current contract but is not effective without the written consent of a
1.16dentist or dental clinic. The dentist must receive a copy of the proposed contract for
1.17renewal along with a disclosure by the dental organization of all material changes in terms
1.18of the contract or methods of reimbursement from the previous contract.
1.19 Sec. 3. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.20to read:
1.21 Subd. 5. Contract amendment. An amendment or change in terms of an existing
1.22contract between a dental organization and a dentist must be disclosed to the dentist at
2.1least 120 days before the effective date of the proposed change. A change to a provider's
2.2fee schedule is not an amendment or change in terms for purposes of this section. A
2.3dental organization may not alter or amend a dental plan contract, or impose an additional
2.4contractual obligation on a dentist or dental clinic, unless the dental organization complies
2.5with the requirements of this subdivision.
2.6 Sec. 4. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
2.7to read:
2.8 Subd. 6. Provider audits. (a) A dental organization is prohibited from recovering
2.9payments or otherwise withholding payments from a provider.
2.10(b) Notwithstanding paragraph (a), a dental organization may recover payments or
2.11withhold payments from a provider after an audit or investigation where the following
2.12circumstances are met:
2.13(1) the dental organization has conducted an audit or investigation of the provider's
2.14actual patient records and claims submissions, reviewed all relevant information and
2.15documentation, and made verified findings following the audit or investigation;
2.16(2) looks back no more than two years from the date the audit or investigation
2.17results are given to the provider; and
2.18(3) the payments or withholding amount do not rely, in any way, on mathematical
2.19extrapolation or other statistical modeling.
2.20(c) If a dental organization conducts a provider audit, the dental organization must
2.21use a licensed Minnesota dentist, who continues to practice chair-side and whose license
2.22is in good standing, to review the charts.
2.23(d) If a dental organization undertakes a provider audit, as referenced in this
2.24subdivision, and determines that payments have been made to a provider for a noncovered
2.25service, the dental organization must issue new explanation of benefit forms advising
2.26patients that they may be responsible for the full amount of the noncovered service.
2.27(e) Payments recovered by a dental organization as a result of a provider audit must
2.28be returned to the entity that sponsored the plan.
2.29(f) As part of any provider audit process, a dental organization shall:
2.30(1) provide a written explanation to the provider of the reason for the audit and the
2.31process the dental organization intends to use to audit the patient charts, as well as a
2.32written explanation of the processes available to the provider once the dental organization
2.33completes its review of the audited patient records;
3.1(2) allow the provider at least 120 days from the date that the provider receives the
3.2verified audit or investigation findings to review, meet, and negotiate a potential informal
3.3resolution to the audit or investigation; and
3.4(3) not be allowed to assess or otherwise require the provider to reimburse the dental
3.5organization for its internal administrative costs, external consultant expenses, attorney
3.6fees, or other costs incurred in conjunction with any audit or investigation.
3.7(g) For the purpose of this section, fraud means an intentional deception
3.8or misrepresentation a dentist or dental clinic makes knowing the deception or
3.9misrepresentation could result in an unauthorized benefit or reimbursement. Abuse
3.10means an incident or practice of a dentist or dental clinic that is inconsistent with
3.11accepted business or financial practices and which results in unnecessary cost to a dental
3.12organization.
3.13 Sec. 5. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
3.14to read:
3.15 Subd. 7. Payment for covered services. (a) Notwithstanding any other provisions
3.16of law, no dental plan or dental provider agreement of a dental organization contracting
3.17for the provision of dental care services may require, directly or indirectly, that a dentist
3.18who is a participating provider provide services to an enrolled participant at a fee set by,
3.19or at a fee subject to the approval of, the dental plan or dental organization, unless the
3.20dental services are covered services.
3.21(b) A health care service contractor or other person providing third-party
3.22administrator services shall not make available any providers in its dentist network to a
3.23plan that sets dental fees for any services except covered services.
3.24(c) For purposes of this section, "covered services" means dental care services for
3.25which a reimbursement is available under an enrollee's plan contract.
3.26 Sec. 6. EFFECTIVE DATE.
3.27Sections 1 to 5 are effective August 1, 2011, and apply to dental plans and provider
3.28agreements entered into or renewed on or after that date.
