SCS/SB 298 - This act enacts provisions relating to payments for health care services.UTILIZATION REVIEWS (Sections 374.500, and 376.1350 to 376.1387)
This act replaces "utilization review organization" with "utilization review entity", and "prospective review" with "prior authorization review" throughout the statutes relating to utilization reviews.
This act adds health care services that are denied under a utilization review to the definition of "adverse determination", including with regard to the reconsideration process. The definition of "certification" is modified to refer to only those health care services approved for coverage which the health carrier or utilization review entity, as defined in the act, has also determined it will pay for. The definitions of "adverse determination" and "certification" are modified to refer to decisions made by "a utilization review entity" rather than a health carrier's "designee utilization review entity". "Clinical review criteria" is modified to include several specific policies and rules, as well as any other criteria or rationale used by a health carrier or utilization review entity to determine appropriateness or necessity of health care services. "Health care service" is modified to specifically include the provision of drugs or durable medical equipment. (Section 376.1350)
Under this act, providers shall be notified immediately upon the carrier making its initial and concurrent review decisions, instead of within 24 hours. Further, the act replaces references to "initial certification" with "certification. (Section 376.1363.1-3)
Currently, notice of an adverse determination is required to include instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination. This act repeals this requirement, specifies that the adverse determination notice shall include a written statement of the clinical rationale, requires notice to the health care provider, and repeals the requirement that notice of the adverse determination must be requested. Written procedures to address a failure or inability of a provider or enrollee to provide all information necessary to make a decision shall be made available on the health carrier's website or provider portal. No utilization review entity shall revoke, limit, condition, or otherwise restrict a prior authorization within 45 working days of its receipt by a health care provider. The prior authorization shall be valid for one year from the date received unless revoked or restricted in writing in accordance with these provisions. Any failure by a utilization review entity to comply with these provisions shall be deemed authorization of the health care services being reviewed. (Section 376.1363.5-8)
For purposes of utilization reviews, a health care service shall be considered medically necessary if it is provided in a manner that is in accordance with generally accepted standards of health care practices; clinically appropriate in terms of the type, frequency, extent, and duration; and not primarily for the economic benefit of the health carrier, nor the convenience of the patient, treating physician, or other health care provider. (Section 376.1363.9)
No later than January 1, 2020, utilization review entities shall accept and respond to requests for prior authorization of drug benefits through a secure electronic transmission using the National Council for Prescription Drugs SCRIPT Standard Version 201310 or a backwards-compatible successor adopted by the United States Department of Health and Human Services. (Section 376.1364.1)
No later than January 1, 2020, the Department of Insurance, Financial Institutions, and Professional Registration shall develop a standard prior authorization form, which all health carriers shall use beginning January 1, 2021. (Section 376.1364)
The act requires health carriers and utilization review entities to make available on its web site any current prior authorization requirements or restrictions, including written clinical criteria. No health carrier or utilization review entity shall amend or implement a new prior authorization requirement or restriction prior to the change being reflected on the carrier or review entity's website. Health carriers and utilization review entities shall provide in-network health care providers with written notice of the new or amended requirement not less than 60 days prior to implementing the requirement or restriction. (Section 376.1372)
This act modifies the panel for a second-level grievance review for an adverse determination to require a majority of persons that are "actively practicing clinical peers licensed to practice medicine" rather than "appropriate clinical peers" in the same or similar specialty as would typically manage the case being reviewed. (Section 376.1385)
The act specifies that if an independent review organization reviews an adverse determination appeal and reverses the adverse determination, the health carrier shall reimburse the Department for any and all fees charged by the independent review organization. (Section 376.1387)
These provisions are similar to provisions in the truly agreed to and finally passed SB 514 (2019), provisions in HCS/HB 751 (2019), and provisions in SS/HB 219 (2019).
METHODS OF REIMBURSEMENT (Section 376.1345)
This act prohibits health carriers and health benefit managers, and entities acting on their behalf, from restricting methods of reimbursement to a method requiring health care providers to pay a fee to redeem the amount of their claim for reimbursement.
Health carriers and health benefit administrators initiating a new method of reimbursement or changing the reimbursement method used shall notify in-network health care providers, and any other providers to whom the carrier or benefit administrator has issued a prior authorization within the past year, whether any fee is required to receive reimbursement through the new or different method, and for health benefit plans issued, delivered, or renewed on or after August 28, 2019, shall allow the provider to select an alternative method of reimbursement which does not require a fee.
Violation of these provisions shall be deemed an unfair trade practice under the Unfair Trade Practice Act.
These provisions are similar to SB 302 (2019), HB 492 (2019), provisions in the truly agreed to and finally passed HB 514 (2019), provisions in the truly agreed to and finally passed SS/SCS/HCS/HB 399 (2019), provisions in SS#2/HB 219 (2019), provisions in HCS/HB 751 (2019), and provisions in HCS/SB 103 (2019).
ERIC VANDER WEERD