Bill Text: OH HB122 | 2009-2010 | 128th General Assembly | Engrossed

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Bill Title: To establish standards for physician designations by health care insurers.

Spectrum: Moderate Partisan Bill (Democrat 30-6)

Status: (Engrossed - Dead) 2010-02-04 - To Insurance, Commerce, & Labor [HB122 Detail]

Download: Ohio-2009-HB122-Engrossed.html

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As Passed by the House

128th General Assembly Regular Session 2009-2010

Sub. H. B. No. 122

Representative Boyd 

Cosponsors: Representatives Hagan, Letson, Winburn, Slesnick, Yuko, Belcher, Blessing, Bolon, Brown, Carney, Celeste, Combs, DeBose, Domenick, Evans, Fende, Foley, Garland, Gerberry, Goyal, Harris, Heard, Huffman, Lehner, Luckie, Lundy, Mallory, Moran, Murray, Pillich, Stewart, Ujvagi, Weddington, Williams, B., Williams, S. 

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A BILL

To enact sections 3964.01 to 3964.03, 3964.05 to

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3964.07, 3964.10 to 3964.12, 3964.15 to 3964.17,

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3964.21 to 3964.25, 3964.27, and 5111.0210 of the

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Revised Code to establish standards for physician

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designations by health care insurers.

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BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1.  That sections 3964.01, 3964.02, 3964.03, 3964.05,	6
3964.06, 3964.07, 3964.10, 3964.11, 3964.12, 3964.15, 3964.16,	7
3964.17, 3964.21, 3964.22, 3964.23, 3964.24, 3964.25, 3964.27,	8
and 5111.0210 of the Revised Code be enacted to read as follows:	9

Sec. 3964.01. As used in this chapter:

10

(A) "Health care insurer" means an entity that offers a	11
policy, contract, or plan for covering the cost of health care	12
services for individuals who are beneficiaries of or enrolled in	13
the policy, contract, or plan, to the extent that the entity and	14
the policy, contract, or plan are subject to the laws of this	15
state. "Health care insurer" includes all of the following:	16

(1) A sickness and accident insurance company authorized to	17
do the business of insurance in this state;	18

(2) A health insuring corporation that holds a certificate of	19
authority issued under Chapter 1751. of the Revised Code;	20

(3) An entity that offers a multiple employer welfare	21
arrangement, as defined in section 1739.01 of the Revised Code;	22

(4) The state, a political subdivision, or any other	23
government entity that offers a public employee health benefit	24
plan.	25

(B) "Physician" means an individual authorized under Chapter	26
4731. of the Revised Code to practice medicine and surgery or	27
osteopathic medicine and surgery.	28

(C) "Physician designation" means a grade, star, tier, or any	29
other rating used by a health care insurer to characterize or	30
represent the insurer's assessment or measurement of a physician's	31
cost efficiency, quality of care, or clinical performance.	32
"Physician designation" does not include either of the following:	33

(1) Information derived solely from satisfaction surveys or	34
other comments provided by individuals who are beneficiaries of or	35
enrolled in a policy, contract, or plan offered by a health care	36
insurer;	37

(2) Information for a program established by a health care	38
insurer to assist individuals with estimating a physician's	39
routine fees for providing services.	40

(D) "Third-party administrator" has the same meaning as	41
"administrator" in section 3959.01 of the Revised Code.	42

Sec. 3964.02. If a health care insurer operates a system for	43
making physician designations, all of the following apply with	44
respect to each physician designation that is made:	45

(A) The health care insurer shall include a quality-of-care	46
component in making the physician designation. Inclusion of the	47
quality-of-care component may be satisfied by incorporating one or	48
more practice guidelines or performance measures pursuant to	49
division (F) of this section. The resulting designation shall	50
include a clear description of the weight given to the	51
quality-of-care component in comparison to other factors used in	52
making the designation.	53

(B) The health care insurer shall use statistical analyses	54
in making the physician designation. The insurer shall use	55
statistical analyses that are accurate, valid, and reliable.	56
Where reasonably possible, the insurer shall use statistical	57
analyses that have been appropriately adjusted to reflect known	58
statistical anomalies, including factors pertaining to patient	59
population, case mix, severity of condition, comorbidities, and	60
outlier events.	61

(C) The health care insurer shall make a physician	62
designation only after completing a period of assessment of data	63
pertinent to the designation. The insurer shall update the data	64
at appropriate intervals.	65

(D) If data from claims for payment are used in making the	66
physician designation, the health care insurer shall use accurate	67
claims data and attribute the data appropriately to the physician.	68
If reasonably available, aggregated claims data shall be used to	69
supplement the insurer's claims data.	70

(E) The health care insurer shall make the physician	71
designation in a manner that recognizes the physician's	72
responsibility for making health care decisions and the financial	73
consequences of those decisions. The financial consequences of the	74
physician's health care decisions shall be attributed to the	75
physician in a manner that is accurate and fair to the physician.	76

(F) If practice guidelines or performance measures are used	77
in making the physician designation, the health care insurer shall	78
use guidelines or measures that are evidence-based, whenever	79
possible; consensus-based, whenever possible; and pertinent to the	80
physician's area of practice, location, and patient-population	81
characteristics. To the maximum extent possible, the insurer shall	82
use practice guidelines or performance measures that have been	83
established by nationally recognized health care organizations,	84
including the national quality forum or its successor, or the AQA	85
alliance or its successor.	86

Sec. 3964.03.  (A) A health care insurer that operates a	87
system for making physician designations shall appoint and pay for	88
an independent ratings examiner, who is approved by the	89
superintendent of insurance, to ensure that the health care	90
insurer is in compliance with the requirements of this chapter.	91
Every six months, the independent ratings examiner shall submit a	92
report to the superintendent of insurance that describes the	93
methods used by the insurer in making physician designations and	94
details the insurer's compliance with this chapter.	95

(B) For purposes of division (A) of this section, the	96
superintendent shall establish a process for approving independent	97
ratings examiners.	98

Sec. 3964.05.  Except as provided in section 3964.06 of the	99
Revised Code, a health care insurer may disclose any or all of its	100
physician designations to any of the following:	101

(A) A physician;

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(B) A patient or potential patient;

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(C) An individual who is or may become a beneficiary of or	104
enrolled in a health care policy, contract, or plan offered by the	105
insurer;	106

(D) Any other individual.

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Sec. 3964.06. (A) When a health care insurer makes a	108
physician designation, including a change in a designation, the	109
insurer shall notify the physician before disclosing the	110
designation to the public. The notice shall be provided in writing	111
and shall inform the physician of both of the following:	112

(1) The process by which the physician may request	113
information under sections 3964.10 and 3964.11 of the Revised	114
Code regarding the method and data used in making the	115
designation;	116

(2) The opportunity to request an appeal of the designation	117
pursuant to section 3964.15 of the Revised Code.	118

(B) After providing the written notice required under	119
division (A) of this section, the health care insurer shall not	120
disclose the physician designation until the latest occurring of	121
the following:	122

(1) Ninety days after providing the notice;

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(2) Thirty days after fulfilling any request for information	124
under section 3964.10 of the Revised Code;	125

(3) Thirty days after fulfilling any request for information	126
under section 3964.11 of the Revised Code;	127

(4) The date that the designation is in compliance with a	128
final decision made pursuant to an appeal requested under section	129
3964.15 of the Revised Code.	130

Sec. 3964.07. (A) When a health care insurer discloses a	131
physician designation under section 3964.05 of the Revised Code,	132
the insurer shall include with the disclosure a statement	133
specifying all of the following:	134

(1) That physician designations are intended to be used only	135
as a guide in selecting a physician;	136

(2) That physician designations should not be the sole factor	137
used in selecting a physician;	138

(3) That physician designations have a risk of error;

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(4) That individuals should discuss physician designations	140
with a physician before a selection is made.	141

(B) The statement required by this section shall accompany	142
the disclosure of the physician designation in a conspicuous	143
manner, shall be provided in writing, and shall be printed in	144
boldface type.	145

Sec. 3964.10. (A) Any of the following may submit a request	146
to a health care insurer asking that the insurer provide a	147
description of the method used by the insurer in making a	148
physician designation and, for a particular designation, a	149
description of all data used in making the designation:	150

(1) The physician who is the subject of the designation;

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(2) A representative of the physician who is the subject of	152
the designation;	153

(3) The superintendent of insurance.

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(B) Not later than forty-five days after receiving a request	155
under this section, the health care insurer shall provide the	156
requested information to the person who submitted the request. In	157
providing the information, the insurer is subject to all of the	158
following:	159

(1) The description of the method used in making the	160
physician designation shall be sufficiently detailed to allow the	161
person who submitted the request to determine the effect of the	162
method on the data used in making the designation. As applicable,	163
the description shall include an explanation of the use of	164
algorithms or studies, the assessment of data, and the application	165
of practice guidelines or performance measures.	166

(2) The description of the data used in making the physician	167
designation shall be made in a manner that is reasonably	168
understandable and allows the person who submitted the request to	169
verify the data against the person's records.	170

(3) If the health care insurer has a contract with another	171
person that prevents the insurer from disclosing all or part of	172
the data used in making the physician designation, the insurer	173
may withhold the data but shall provide sufficient information to	174
allow the person who submitted the request to determine how the	175
withheld data affected the designation.	176

Sec. 3964.11. After receiving a description of a health care	177
insurer's method used in making a physician designation pursuant	178
to a request submitted under section 3964.10 of the Revised Code,	179
the recipient may submit a request to the insurer asking that the	180
insurer provide the complete method used by the insurer in making	181
the physician designation.	182

Not later than thirty days after receiving a request under	183
this section, the health care insurer shall provide the requested	184
information to the person who submitted the request.	185

Sec. 3964.12. Neither sections 1333.61 to 1333.69 of the	186
Revised Code nor any other provision of the Revised Code	187
pertaining to trade secrets excuses a health care insurer from	188
complying with sections 3964.10 and 3964.11 of the Revised Code.	189

Sec. 3964.15. A health care insurer that operates a system	190
for making physician designations shall afford a physician who is	191
subject to the physician designation system an opportunity to	192
appeal the insurer's decision regarding the physician's	193
designation, including a decision by the insurer to change a	194
previous designation or to make no designation. In appealing the	195
decision, the physician may be assisted by a representative.	196

Except for modifications made in accordance with section	197
3964.17 of the Revised Code, information regarding an appeal	198
requested under this section shall not be disclosed to the public.	199

Sec. 3964.16. A health care insurer shall establish	200
procedures for the conduct of appeals under section 3964.15 of the	201
Revised Code. At a minimum, the procedures established by the	202
insurer shall include all of the following:	203

(A) A reasonable method for a physician or a physician's	204
representative to provide notice to the insurer that an appeal is	205
being sought;	206

(B) Consideration of any information obtained by the	207
physician or the physician's representative pursuant to section	208
3964.10 or 3964.11 of the Revised Code;	209

(C) If requested by the physician or the physician's	210
representative, consideration of an explanation of the decision	211
regarding the physician designation, with the explanation supplied	212
by the person or persons identified by the health care insurer as	213
being responsible for making the designation decision;	214

(D) With respect to the data and method used by the insurer	215
to make the physician designation decision, an opportunity for	216
the physician or the physician's representative to submit to the	217
insurer corrected data for the insurer's consideration and to have	218
the appropriateness of the method evaluated by the insurer;	219

(E) Disclosure of the name, title, qualifications, and	220
relationship to the health care insurer of the person or persons	221
designated by the insurer as responsible for conducting the	222
appeal proceedings and making the final decision;	223

(F) If requested by the physician or the physician's	224
representative, an opportunity to meet with the person or persons	225
responsible for conducting the appeal proceedings and making the	226
final decision, either by meeting in person at a location	227
reasonably convenient to the physician or the physician's	228
representative or by teleconference.	229

(G) Completion of the appeals process not later than	230
forty-five days after the physician or physician's representative	231
provides notice that an appeal is being sought, unless another	232
time is agreed to by the physician or the physician's	233
representative;	234

(H) Issuance of a written final decision that states the	235
reasons for upholding, modifying, or rejecting the physician	236
designation decision subject to the appeal.	237

Sec. 3964.17. If the final decision regarding an appeal	238
under section 3964.15 of the Revised Code is in favor of the	239
physician, the health care insurer shall modify its designation	240
of the physician in accordance with the final decision. In	241
modifying the designation, the insurer is subject to both of the	242
following:	243

(A) If the designation was disclosed to the public before the	244
appeal was made, the insurer shall make the necessary changes to	245
the designation not later than thirty days after the final	246
decision regarding the appeal is made.	247

(B) If the designation was not disclosed to the public before	248
the appeal was made, the insurer shall make the necessary changes	249
to the designation before the designation is disclosed to the	250
public.	251

Sec. 3964.21. A health care insurer shall not fail to comply	252
with sections 3964.02 to 3964.17 of the Revised Code or any rules	253
adopted under section 3964.27 of the Revised Code.	254

Sec. 3964.22. In the case of a health care insurer that is	255
regulated by the department of insurance, a series of violations	256
of section 3964.21 of the Revised Code that, taken together,	257
constitutes a pattern or practice of violating that section shall	258
be considered an unfair and deceptive act or practice in the	259
business of insurance under sections 3901.19 to 3901.26 of the	260
Revised Code.	261

Sec. 3964.23. A physician who is adversely affected by a	262
violation of section 3964.21 of the Revised Code has a cause of	263
action against the health care insurer and may seek a declaratory	264
judgment, an injunction, or other appropriate relief.	265

Sec. 3964.24. Any provision of a contractual arrangement	266
between a health care insurer and physician that limits any of the	267
physician's rights granted by this chapter or that is otherwise	268
contrary to the provisions of this chapter is unenforceable.	269

Sec. 3964.25.  This chapter applies to a third-party	270
administrator in the same manner that the chapter applies to a	271
health care insurer.	272

Sec. 3964.27.  The superintendent of insurance may adopt	273
rules as the superintendent considers necessary to carry out the	274
purposes of this chapter. The rules shall be adopted in accordance	275
with Chapter 119. of the Revised Code.	276

Sec. 5111.0210. Chapter 3964. of the Revised Code applies to	277
the medicaid program in the same manner that the chapter applies	278
to a health care insurer, as defined in section 3964.01 of the	279
Revised Code.	280