Bill Text: MS HB391 | 2015 | Regular Session | Introduced
Bill Title: Physician; require health care facilities & managed care organizations to provide fair process before adverse actions affecting.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2015-02-03 - Died In Committee [HB391 Detail]
Download: Mississippi-2015-HB391-Introduced.html
MISSISSIPPI LEGISLATURE
2015 Regular Session
To: Public Health and Human Services; Judiciary A
By: Representative Chism
House Bill 391
AN ACT TO BE KNOWN AS THE PHYSICIAN FAIR PROCESS PROTECTIONS ACT; TO PROVIDE THAT A HOSPITAL, HEALTH SYSTEM, HEALTH CARE FACILITY OR MANAGED CARE ORGANIZATION SHALL NOT EFFECT AN ADVERSE ACTION WITH RESPECT TO A PHYSICIAN WITHOUT FIRST PROVIDING THE PHYSICIAN WITH THE FAIR PROCESS PROTECTIONS REQUIRED BY THIS ACT; TO REQUIRE THAT THE PHYSICIAN BE GIVEN WRITTEN NOTICE INFORMING HIM OF THE PROPOSED ACTION, WHICH NOTICE MUST CONTAIN A DETAILED EXPLANATION OF THE REASONS FOR THE PROPOSED ADVERSE ACTION THAT ARE OF SUFFICIENT DETAIL TO ENABLE THE PHYSICIAN TO CHALLENGE THE ACTION, MUST REFERENCE AND MAKE AVAILABLE TO THE PHYSICIAN FOR REVIEW THE EVIDENCE OR DOCUMENTATION UNDERLYING THE DECISION TO PURSUE THE PROPOSED ADVERSE ACTION, AND MUST INFORM THE PHYSICIAN OF HIS RIGHT TO AN IN-PERSON HEARING AT WHICH HE MAY CHALLENGE THE PROPOSED ADVERSE ACTION; TO PRESCRIBE THE REQUIREMENTS FOR THE IN-PERSON HEARING AND WHEN THE DECISION OF THE HEARING PANEL WILL BECOME EFFECTIVE; TO PROVIDE THAT THE PROVISIONS OF THIS ACT CANNOT BE WAIVED BY CONTRACT; TO AMEND SECTION 83-41-409, MISSISSIPPI CODE OF 1972, TO CONFORM TO THE PRECEDING PROVISIONS; TO BRING FORWARD SECTION 83-41-403, MISSISSIPPI CODE OF 1972, FOR THE PURPOSES OF POSSIBLE AMENDMENT; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. (1) This section shall be known as the Physician Fair Process Protections Act.
(2) For purposes of this section:
(a) "Hospital" means a facility licensed by the State Department of Health under Section 41-9-1 et seq.
(b) "Health care facility" means a hospital, skilled nursing facility, intermediate care facility for the mentally retarded, ambulatory surgical facility, home health agency, psychiatric residential treatment facility and any other facility providing health care services that is licensed by the State Department of Health.
(c) "Managed care organization" means the same as the definition of the term "managed care entity" in Section 83-41-403.
(d) "Physician" means a person licensed by the State Board of Medical Licensure under Section 73-25-1 et seq.
(f) "Adverse action" means a decision by: (i) a hospital, health system or health care facility to terminate, deny, restrict, limit or otherwise condition a physician's clinical privileges or membership on the medical staff; or (ii) a managed care organization to terminate, deny, restrict, limit or otherwise condition a physician's participation in one or more provider networks contractually or otherwise affiliated with the managed care organization.
(3) A hospital, health system, health care facility or managed care organization shall not effect an adverse action with respect to a physician without first providing the physician with the fair process protections required by subsection (4) of this section.
(4) Before taking any action described in subsection (3) of this section, the hospital, health system, health care facility or managed care organization must provide the affected physician with written notice, sent by certified mail, return receipt requested, informing the physician of the proposed action. The notice must:
(a) Contain an explanation of the reasons for the proposed adverse action that are of sufficient detail to enable the physician to challenge the proposed adverse action;
(b) Reference the evidence or documentation underlying the decision to pursue the proposed adverse action, which the hospital, health system, health care facility or managed
care organization must make available for the physician's review within seven (7) working days of the date of the physician's request;
(c) Inform the physician of his or her right to a full, fair, objective and independent in-person hearing, under rules established by the Commissioner of Insurance by administrative rule, at which the physician may challenge the proposed adverse action; and
(d) Inform the physician of his or her right to be represented by legal counsel to challenge the proposed adverse action.
(5) The notice described in subsection (4) of this section must be received by the physician at least sixty (60) working days before the date or dates on which the hearing described in subsection (4)(c) is scheduled.
(6) The in-person hearing described in subsection (4)(c) of this section must satisfy the following requirements:
(a) The hearing must be conducted by a panel of at least three (3) persons selected according to procedures promulgated by organizations nationally recognized as having expertise with respect to resolution of health care-related disputes; and
(b) At least one (1) member of the hearing panel must be an actively practicing physician in the same specialty as the affected physician.
(7) The hearing panel must provide the physician with a
written decision no later than sixty (60) calendar days after the close of the hearing. The written decision must contain a detailed description of all of the bases of the decision and any
applicable contract language.
(8) A decision to effect the adverse action may not become effective until not less than sixty (60) days after the receipt by the physician of the health panel's decision or, if applicable, until the termination date of the physician's agreement with the managed care organization, health system, hospital or health care facility, whichever is earlier.
(9) The provisions of this section cannot be waived by contract, and any contractual arrangement in conflict with the provisions of this section or that purport to waive any requirements of this section are null and void.
SECTION 2. Section 83-41-409, Mississippi Code of 1972, is amended as follows:
83-41-409. In order to be certified and recertified under this article, a managed care plan shall:
(a) Provide enrollees or other applicants with written information on the terms and conditions of coverage in easily understandable language including, but not limited to, information on the following:
(i) Coverage provisions, benefits, limitations, exclusions and restrictions on the use of any providers of care;
(ii) Summary of utilization review and quality assurance policies; and
(iii) Enrollee financial responsibility for copayments, deductibles and payments for out-of-plan services or supplies;
(b) Demonstrate that its provider network has providers of sufficient number throughout the service area to assure reasonable access to care with minimum inconvenience by plan enrollees;
(c) File a summary of the plan credentialing criteria and process and policies with the State Department of Insurance to be available upon request;
(d) Provide a participating provider with a copy of his/her individual profile if economic or practice profiles, or both, are used in the credentialing process upon request;
(e) When any provider application for participation is denied or contract is terminated, the reasons for denial or termination shall be reviewed by the managed care plan upon the request of the provider, and if the provider is a physician, the managed care entity shall provide the physician with the fair process protections required by Section 1 of this act; and
(f) Establish procedures to ensure that all applicable state and federal laws designed to protect the confidentiality of medical records are followed.
SECTION 3. Section 83-41-403, Mississippi Code of 1972, is brought forward as follows:
83-41-403. As used in this article:
(a) "Department" means the Mississippi Department of Insurance.
(b) "Managed care plan" means a plan operated by a managed care entity as described in subparagraph (c) that provides for the financing and delivery of health care services to persons enrolled in such plan through:
(i) Arrangements with selected providers to furnish health care services;
(ii) Explicit standards for the selection of participating providers;
(iii) Organizational arrangements for ongoing quality assurance, utilization review programs and dispute resolution; and
(iv) Financial incentives for persons enrolled in the plan to use the participating providers, products and procedures provided for by the plan.
(c) "Managed care entity" includes a licensed insurance company, hospital or medical service plan, health maintenance organization (HMO), an employer or employee organization, or a managed care contractor as described in subparagraph (d) that operates a managed care plan.
(d) "Managed care contractor" means a person or corporation that:
(i) Establishes, operates or maintains a network of participating providers;
(ii) Conducts or arranges for utilization review activities; and
(iii) Contracts with an insurance company, a hospital or medical service plan, an employer or employee organization, or any other entity providing coverage for health care services to operate a managed care plan.
(e) "Participating provider" means a physician, hospital, pharmacy, pharmacist, dentist, nurse, chiropractor, optometrist, or other provider of health care services licensed or certified by the state, that has entered into an agreement with a managed care entity to provide services, products or supplies to a patient enrolled in a managed care plan.
SECTION 4. This act shall take effect and be in force from and after July 1, 2015.
