HP0704, LD 1006, item 1, An Act To Clarify Transparency of Medical Provider Profiling Programs Used by Insurance Companies and Other Providers of Health Insurance

An Act To Clarify Transparency of Medical Provider Profiling Programs Used by Insurance Companies and Other Providers of Health Insurance

Be it enacted by the People of the State of Maine as follows:

Sec. 1. 24-A MRSA §2694-A, sub-§1, as enacted by PL 2009, c. 350, Pt. B, §1, is amended to read:

1. Performance measurement, reporting and tiering programs. An insurer delivering or issuing for delivery within the State any individual health insurance policy or group health insurance policy or certificate shall annually file with the superintendent on or before October 1, 2010 and annually by October 1st in subsequent years a full and true statement of its criteria, standards, practices, procedures and programs that measure physician performance or tier physician performance with respect to quality, cost or cost-efficiency. The statement must be on a form prepared by the superintendent and may be supplemented by additional information required by the superintendent. The statement must be verified by the oath of the insurer's president or vice-president, and secretary or chief medical officer. A filing and supporting information are public records notwithstanding Title 1, section 402, subsection 3, paragraph B.

Sec. 2. 24-A MRSA §4301-A, sub-§16-A, as enacted by PL 2009, c. 439, Pt. B, §1, is amended to read:

16-A. Provider profiling program. "Provider profiling program" means a program that uses provider data in order to rate or rank provider quality , cost or efficiency of care by the use of a grade, star, tier, rating or any other form of designation , including designations made pursuant to section 4303, subsection 1.

Sec. 3. 24-A MRSA §4303, sub-§2, ¶E, as enacted by PL 2009, c. 439, Pt. B, §5, is amended to read:

E. A carrier with a provider profiling program shall:

(1) Disclose to providers the methodologies, criteria, data and analysis used to evaluate provider quality, performance , cost, including but not limited to unit cost, price and cost-efficiency ratings and, upon request from a provider evaluated on these bases, provide to that provider electronic copies of the data associated with the requesting provider and all adjustments to that data;

(2) Create and share with providers their provider profile at least 60 days prior to using or publicly disclosing the results of the provider profiling program;

(3) Afford providers the opportunity to correct errors, submit additional information for consideration and seek review of data and performance ratings; and

(4) Afford providers due process appeal rights to challenge the profiling determination described in this subsection and by Bureau of Insurance Rule Chapter 850, Health Plan Accountability.

If a carrier has a provider profiling program that includes out-of-network providers, a carrier must meet the requirements of this paragraph with regard to an out-of-network provider as well as for a provider in a carrier's network.

summary

This bill requires that any cost metric used by insurance providers in a provider profiling program is covered by the existing transparency provisions in the health plan improvement laws. The bill also requires carriers to provide copies of the data methodology used in the metric to affected providers. The purpose of this bill is to require all insurance providers, including the state health plan and other government insurance programs, to be included in this transparency obligation.

HP0704 LD 1006	Session - 126th Maine Legislature		LR 1402 Item 1
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