Bill Text: MN HF122 | 2011-2012 | 87th Legislature | Engrossed
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-Engrossed.html
1.2relating to insurance; regulating dental provider 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 provider contract. "Dental provider contract" means a written
1.9agreement between a dentist or dental clinic and dental organization to provide dental
1.10care services.
1.11 Sec. 2. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.12to read:
1.13 Subd. 4. Contract amendment. An amendment or change in terms of an existing
1.14contract between a dental organization and a dentist must be disclosed to the dentist at
1.15least 90 days before the effective date of the proposed change.
1.16 Sec. 3. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.17to read:
1.18 Subd. 5. Provider audits. (a) A dental organization is prohibited from recovering
1.19payments or otherwise withholding payments from a provider.
1.20(b) Notwithstanding paragraph (a), a dental organization may recover payments or
1.21withhold payments from a provider after an audit or investigation where the following
1.22circumstances are met:
2.1(1) the dental organization has conducted an audit or investigation of the provider's
2.2actual patient records and claims submissions, reviewed all relevant information and
2.3documentation, and made verified findings following the audit or investigation;
2.4(2) looks back no more than 42 months from the date the audit or investigation
2.5results are given to the provider, except for an audit of public programs or where fraud
2.6has occurred; and
2.7(3) the payments or withholding amount do not rely, in any way, on mathematical
2.8extrapolation or other statistical modeling.
2.9(c) If a dental organization conducts a provider audit, the dental organization must
2.10use a licensed dentist whose license is in good standing to review the charts.
2.11(d) As part of any provider audit process, a dental organization shall:
2.12(1) provide a written explanation to the provider of the reason for the audit and the
2.13process the dental organization intends to use to audit the patient charts, as well as a
2.14written explanation of the processes available to the provider once the dental organization
2.15completes its review of the audited patient records; and
2.16(2) allow the provider at least 75 days from the date that the provider receives
2.17the verified audit or investigation findings to review, meet, and negotiate an informal
2.18resolution to the audit or investigation.
2.19 Sec. 4. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
2.20to read:
2.21 Subd. 6. Payment for covered services. (a) No contract of any dental plan or
2.22dental organization that covers any dental services or dental provider agreement with a
2.23dentist may require, directly or indirectly, that a dentist provide services to an enrolled
2.24participant at a fee set by, or at a fee subject to the approval of, the dental plan or dental
2.25organization unless the dental services are covered services.
2.26 (b) A dental plan or dental organization or other person providing third-party
2.27administrator services shall not make available any providers in its dentist network to a
2.28plan that sets dental fees for any services except covered services.
2.29 (c) "Covered services" means dental care services for which a reimbursement
2.30is available under an enrollee's plan contract, or for which a reimbursement would
2.31be available but for the application of contractual limitations such as deductibles,
2.32co-payments, coinsurance, waiting periods, annual or lifetime maximums, frequency
2.33limitations, alternative benefit payments, or any other limitation.
2.34 Sec. 5. EFFECTIVE DATE.
3.1Sections 1 to 4 are effective August 1, 2011, and apply to dental plans and provider
3.2agreements 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 provider contract. "Dental provider contract" means a written
1.9agreement between a dentist or dental clinic and dental organization to provide dental
1.10care services.
1.11 Sec. 2. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.12to read:
1.13 Subd. 4. Contract amendment. An amendment or change in terms of an existing
1.14contract between a dental organization and a dentist must be disclosed to the dentist at
1.15least 90 days before the effective date of the proposed change.
1.16 Sec. 3. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
1.17to read:
1.18 Subd. 5. Provider audits. (a) A dental organization is prohibited from recovering
1.19payments or otherwise withholding payments from a provider.
1.20(b) Notwithstanding paragraph (a), a dental organization may recover payments or
1.21withhold payments from a provider after an audit or investigation where the following
1.22circumstances are met:
2.1(1) the dental organization has conducted an audit or investigation of the provider's
2.2actual patient records and claims submissions, reviewed all relevant information and
2.3documentation, and made verified findings following the audit or investigation;
2.4(2) looks back no more than 42 months from the date the audit or investigation
2.5results are given to the provider, except for an audit of public programs or where fraud
2.6has occurred; and
2.7(3) the payments or withholding amount do not rely, in any way, on mathematical
2.8extrapolation or other statistical modeling.
2.9(c) If a dental organization conducts a provider audit, the dental organization must
2.10use a licensed dentist whose license is in good standing to review the charts.
2.11(d) As part of any provider audit process, a dental organization shall:
2.12(1) provide a written explanation to the provider of the reason for the audit and the
2.13process the dental organization intends to use to audit the patient charts, as well as a
2.14written explanation of the processes available to the provider once the dental organization
2.15completes its review of the audited patient records; and
2.16(2) allow the provider at least 75 days from the date that the provider receives
2.17the verified audit or investigation findings to review, meet, and negotiate an informal
2.18resolution to the audit or investigation.
2.19 Sec. 4. Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
2.20to read:
2.21 Subd. 6. Payment for covered services. (a) No contract of any dental plan or
2.22dental organization that covers any dental services or dental provider agreement with a
2.23dentist may require, directly or indirectly, that a dentist provide services to an enrolled
2.24participant at a fee set by, or at a fee subject to the approval of, the dental plan or dental
2.25organization unless the dental services are covered services.
2.26 (b) A dental plan or dental organization or other person providing third-party
2.27administrator services shall not make available any providers in its dentist network to a
2.28plan that sets dental fees for any services except covered services.
2.29 (c) "Covered services" means dental care services for which a reimbursement
2.30is available under an enrollee's plan contract, or for which a reimbursement would
2.31be available but for the application of contractual limitations such as deductibles,
2.32co-payments, coinsurance, waiting periods, annual or lifetime maximums, frequency
2.33limitations, alternative benefit payments, or any other limitation.
2.34 Sec. 5. EFFECTIVE DATE.
3.1Sections 1 to 4 are effective August 1, 2011, and apply to dental plans and provider
3.2agreements entered into or renewed on or after that date.
