Bill Text: OH SB98 | 2009-2010 | 128th General Assembly | Introduced

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

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2009-04-07 - To Insurance, Commerce, & Labor [SB98 Detail]

Download: Ohio-2009-SB98-Introduced.html

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As Introduced

128th General Assembly Regular Session 2009-2010

S. B. No. 98

Senator Patton 

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A BILL

To enact sections 3964.01, 3964.02, 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 3964.24, and 5111.0210 of the Revised

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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, 3964.05, 3964.06,	6
3964.07, 3964.10, 3964.11, 3964.12, 3964.15, 3964.16, 3964.17,	7
3964.21, 3964.22, 3964.23, 3964.24, and 5111.0210 of the Revised	8
Code be enacted to read as follows:	9

Sec. 3964.01. As used in this chapter:

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(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 entity" 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

Sec. 3964.02. If a health care insurer operates a system for	41
making physician designations, all of the following apply with	42
respect to each physician designation that is made:	43

(A) The health care insurer shall include a quality-of-care	44
component in making the physician designation. Inclusion of the	45
quality-of-care component may be satisfied by incorporating one or	46
more practice guidelines or performance measures pursuant to	47
division (F) of this section. The resulting designation shall	48
include a clear description of the weight given to the	49
quality-of-care component in comparison to other factors used in	50
making the designation.	51

(B) The health care insurer shall use statistical analyses	52
in making the physician designation. The insurer shall use	53
statistical analyses that are accurate, valid, and reliable.	54
Where reasonably possible, the insurer shall use statistical	55
analyses that have been appropriately adjusted to reflect known	56
statistical anomalies, including factors pertaining to patient	57
population, case mix, severity of condition, comorbidities, and	58
outlier events.	59

(C) The health care insurer shall make a physician	60
designation only after completing a period of assessment of data	61
pertinent to the designation. The insurer shall update the data	62
at appropriate intervals.	63

(D) If data from claims for payment are used in making the	64
physician designation, the health care insurer shall use accurate	65
claims data and attribute the data appropriately to the physician.	66
If reasonably available, aggregated claims data shall be used to	67
supplement the insurer's claims data.	68

(E) The health care insurer shall make the physician	69
designation in a manner that recognizes the physician's	70
responsibility for making health care decisions and the financial	71
consequences of those decisions. The financial consequences of the	72
physician's health care decisions shall be attributed to the	73
physician in a manner that is accurate and fair to the physician.	74

(F) If practice guidelines or performance measures are used	75
in making the physician designation, the health care insurer shall	76
use guidelines or measures that are evidence-based, whenever	77
possible; consensus-based, whenever possible; and pertinent to the	78
physician's area of practice, location, and patient-population	79
characteristics. To the maximum extent possible, the insurer shall	80
use practice guidelines or performance measures that have been	81
established by nationally recognized health care organizations,	82
including the national quality forum or its successor, or the AQA	83
alliance or its successor.	84

Sec. 3964.05.  Except as provided in section 3964.06 of the	85
Revised Code, a health care insurer may disclose any or all of its	86
physician designations to any of the following:	87

(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	90
enrolled in a health care policy, contract, or plan offered by the	91
insurer;	92

(D) Any other individual.

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Sec. 3964.06. (A) When a health care insurer makes a	94
physician designation, including a change in a designation, the	95
insurer shall notify the physician before disclosing the	96
designation to the public. The notice shall be provided in writing	97
and shall inform the physician of both of the following:	98

(1) The process by which the physician may request	99
information under sections 3964.10 and 3964.11 of the Revised	100
Code regarding the method and data used in making the	101
designation;	102

(2) The opportunity to request an appeal of the designation	103
pursuant to section 3964.15 of the Revised Code.	104

(B) After providing the written notice required under	105
division (A) of this section, the health care insurer shall not	106
disclose the physician designation until the latest occurring of	107
the following:	108

(1) Forty-five days after providing the notice;

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(2) Fifteen days after fulfilling any request for information	110
under section 3964.10 of the Revised Code;	111

(3) Fifteen days after fulfilling any request for information	112
under section 3964.11 of the Revised Code;	113

(4) The date that the designation is in compliance with a	114
final decision made pursuant to an appeal requested under section	115
3964.15 of the Revised Code.	116

Sec. 3964.07. (A) When a health care insurer discloses a	117
physician designation under section 3964.05 of the Revised Code,	118
the insurer shall include with the disclosure a statement	119
specifying all of the following:	120

(1) That physician designations are intended to be used only	121
as a guide in selecting a physician;	122

(2) That physician designations should not be the sole factor	123
used in selecting a physician;	124

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

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(4) That individuals should discuss physician designations	126
with a physician before a selection is made.	127

(B) The statement required by this section shall accompany	128
the disclosure of the physician designation in a conspicuous	129
manner, shall be provided in writing, and shall be printed in	130
boldface type.	131

Sec. 3964.10. (A) Any of the following may submit a request	132
to a health care insurer asking that the insurer provide a	133
description of the method used by the insurer in making a	134
physician designation and, for a particular designation, a	135
description of all data used in making the designation:	136

(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	138
the designation;	139

(3) The superintendent of insurance.

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(B) Not later than forty-five days after receiving a request	141
under this section, the health care insurer shall provide the	142
requested information to the person who submitted the request. In	143
providing the information, the insurer is subject to all of the	144
following:	145

(1) The description of the method used in making the	146
physician designation shall be sufficiently detailed to allow the	147
person who submitted the request to determine the effect of the	148
method on the data used in making the designation. As applicable,	149
the description shall include an explanation of the use of	150
algorithms or studies, the assessment of data, and the application	151
of practice guidelines or performance measures.	152

(2) The description of the data used in making the physician	153
designation shall be made in a manner that is reasonably	154
understandable and allows the person who submitted the request to	155
verify the data against the person's records.	156

(3) If the health care insurer has a contract with another	157
person that prevents the insurer from disclosing all or part of	158
the data used in making the physician designation, the insurer	159
may withhold the data but shall provide sufficient information to	160
allow the person who submitted the request to determine how the	161
withheld data affected the designation.	162

Sec. 3964.11. After receiving a description of a health care	163
insurer's method used in making a physician designation pursuant	164
to a request submitted under section 3964.10 of the Revised Code,	165
the recipient may submit a request to the insurer asking that the	166
insurer provide the complete method used by the insurer in making	167
the physician designation.	168

Not later than thirty days after receiving a request under	169
this section, the health care insurer shall provide the requested	170
information to the person who submitted the request.	171

Sec. 3964.12. Neither sections 1333.61 to 1333.69 of the	172
Revised Code nor any other provision of the Revised Code	173
pertaining to trade secrets excuses a health care insurer from	174
complying with sections 3964.10 and 3964.11 of the Revised Code.	175

Sec. 3964.15. A health care insurer that operates a system	176
for making physician designations shall afford a physician who is	177
subject to the physician designation system an opportunity to	178
appeal the insurer's decision regarding the physician's	179
designation, including a decision by the insurer to change a	180
previous designation or to make no designation. In appealing the	181
decision, the physician may be assisted by a representative.	182

Sec. 3964.16. A health care insurer shall establish	183
procedures for the conduct of appeals under section 3964.15 of the	184
Revised Code. At a minimum, the procedures established by the	185
insurer shall include all of the following:	186

(A) A reasonable method for a physician or a physician's	187
representative to provide notice to the insurer that an appeal is	188
being sought;	189

(B) Consideration of any information obtained by the	190
physician or the physician's representative pursuant to section	191
3964.10 or 3964.11 of the Revised Code;	192

(C) If requested by the physician or the physician's	193
representative, consideration of an explanation of the decision	194
regarding the physician designation, with the explanation supplied	195
by the person or persons identified by the health care insurer as	196
being responsible for making the designation decision;	197

(D) With respect to the data and method used by the insurer	198
to make the physician designation decision, an opportunity for	199
the physician or the physician's representative to submit to the	200
insurer corrected data for the insurer's consideration and to have	201
the appropriateness of the method evaluated by the insurer;	202

(E) Disclosure of the name, title, qualifications, and	203
relationship to the health care insurer of the person or persons	204
designated by the insurer as responsible for conducting the	205
appeal proceedings and making the final decision;	206

(F) If requested by the physician or the physician's	207
representative, an opportunity to meet with the person or persons	208
responsible for conducting the appeal proceedings and making the	209
final decision, either by meeting in person at a location	210
reasonably convenient to the physician or the physician's	211
representative or by teleconference.	212

(G) Completion of the appeals process not later than	213
forty-five days after the physician or physician's representative	214
provides notice that an appeal is being sought, unless another	215
time is agreed to by the physician or the physician's	216
representative;	217

(H) Issuance of a written final decision that states the	218
reasons for upholding, modifying, or rejecting the physician	219
designation decision subject to the appeal.	220

Sec. 3964.17. If the final decision regarding an appeal	221
under section 3964.15 of the Revised Code is in favor of the	222
physician, the health care insurer shall modify its designation	223
of the physician in accordance with the final decision. In	224
modifying the designation, the insurer is subject to both of the	225
following:	226

(A) If the designation was disclosed to the public before the	227
appeal was made, the insurer shall make the necessary changes to	228
the designation not later than thirty days after the final	229
decision regarding the appeal is made.	230

(B) If the designation was not disclosed to the public before	231
the appeal was made, the insurer shall make the necessary changes	232
to the designation before the designation is disclosed to the	233
public.	234

Sec. 3964.21. A health care insurer shall not fail to comply	235
with sections 3964.02 to 3964.17 of the Revised Code.	236

Sec. 3964.22. In the case of a health care insurer that is	237
regulated by the department of insurance, a series of violations	238
of section 3964.21 of the Revised Code that, taken together,	239
constitutes a pattern or practice of violating that section shall	240
be considered an unfair and deceptive act or practice in the	241
business of insurance under sections 3901.19 to 3901.26 of the	242
Revised Code.	243

Sec. 3964.23. A physician who is adversely affected by a	244
violation of section 3964.21 of the Revised Code has a cause of	245
action against the health care insurer and may seek a declaratory	246
judgment, an injunction, or other appropriate relief.	247

Sec. 3964.24. Any provision of a contractual arrangement	248
between a health care insurer and physician that limits any of the	249
physician's rights granted by this chapter or that is otherwise	250
contrary to the provisions of this chapter is unenforceable.	251

Sec. 5111.0210. Chapter 3964. of the Revised Code applies to	252
the medicaid program in the same manner that the chapter applies	253
to a health care insurer, as defined in section 3964.01 of the	254
Revised Code.	255