Cover: Know Your Legal Rights - A new and exclusive benefit for CMS members

Tuesday, May 01, 2018 12:00 PM

Searchable, online database compiles years of public policy victories for physicians to use in disputes with health plans

by Marilyn Rissmiller, Senior Director, Division of Health Care Financing

Although it may sometimes seem like the deck is stacked, Colorado physicians have rights in disputes with health plans. Lots of them. And thanks to a new tool from the Colorado Medical Society and the statewide network of CMS component societies, these rights are easily searchable in one place.

The arsenal of state laws that grant important provider protections comes from decades of work by CMS and allies over the course of many legislative sessions and regulatory hearings. But these legal rights are spread across numerous statutes and before now were not readily available, making it difficult to find and deploy these rights to counter health plan barriers to care. CMS staff combed years of statutes to produce helpful summaries of physician rights and incorporated this information into a list of topics easily searchable in a new members-only online database: Know Your Legal Rights.

With the deployment of Know Your Legal Rights, available at www.cms.org/kylr, Colorado physicians and their practice staff are now just a keystroke away from knowing the legal tools already available and how to use them effectively.

A few of the highlights from the new tool include summaries and citations for:

• Protections from physician profiling,
• Expedited prior authorization and referrals,
• Guaranteed telehealth coverage,
• Protection against anti-retaliation,
• Help with narrow networks,
• Guaranteed timely payment,
• Fairness in contracting, and
• The right to appeals.

See the highlight box below for a full list of topics covered.

A two-minute instructional “how-to” video on the Know Your Legal Rights database is available on the database landing page. Members must be logged into the CMS website to access the tool. Staff of CMS members can request a login by contacting membership@cms.org with your name, the name of the practice, and a list of the physicians at your practice (one of whom must be a CMS member).

The launch of Know Your Legal Rights and the years of work that secured these rights are your medical society dues dollars at work. Annual CMS member surveys continue to demonstrate that health plans have too much power over physicians and that care quality, access and professional satisfaction are negatively affected by this imbalance. CMS’ focus on the many inequities in the current multi-payer system is critical so that interactions between physicians and insurance companies can center on value rather than market share and volume.

“Health care delivery and financing is increasingly complex, and our patchwork of payers results in an unnecessarily complicated system,” said Denver ophthalmologist Alan Kimura, MD, MPH. “As a practicing physician, my direct experience of this complexity is at times baffling to comprehend, as it is frustrating to fix. The anxiety all physicians feel is the product of uncertainty and powerlessness. The anxiolytic, if you will, requires working to reduce the uncertainty overlaid upon our practices by the payers, and reclaiming our power as physicians. Contractual language matters.”

“Serving alongside dedicated physician colleagues in CMS, I bear direct witness that CMS has proven to be our best ally in this struggle against overbearing legislation and regulation,” Kimura said. “Legal rights protecting physicians from payer abuse are not handed to us, but rather must be actively defended.”

The Colorado Medical Society and the component societies will continue to work with the General Assembly and the state’s regulators to enact and refine the laws and rules governing medical practice, all those who review and pay physicians’ bills, provide credentialing, and perform just about any other action that influences physicians’ clinical and business judgement.

And with this work in the legislative and regulatory spheres, the list of provider protections in Colorado will grow.

Much more is planned for this robust tool. Send feedback by email to membership@cms.org.

Physician protections contained in Know Your Legal Rights

The Know Your Legal Rights database is your exclusive doctor-friendly way to search and find what you need to know about your rights under Colorado law.

• Access plan [Network adequacy]
• Advance payment tax credits
• Appeal of designation
• Assignment of benefits [nonprofit]
• Assignment of benefits
• Carrier-provider dispute resolution
• Clean claim requirements
• Continuity of care
• Contracts with health care providers
• Coordination of benefits
• De-selection, termination, non-renewal or tiering
• Dispute resolution
• Eligibility verification
• Experimental/investigational
• External review
• Fee schedule
• Gag clause
• Grace period
• ID card
• Independent external review
• Interest payment
• Intermediaries
• Internal review, utilization review
• Investigational
• List of plans, product offerings with participation status
• Material change to contract
• Medical necessity denial
• Network adequacy standards
• Non-participating physician services
• Non-renewal of contract
• Notification of administrative policies
• Out-of-Network emergency services
• Out-of-network services at in-network facility
• PCP standing referral
• Participation list
• Physician designation and disclosure
• Physician terminating contract
• Pre-authorization (prior authorization, pre-certification)
• Pre-certification
• Prior authorization
• Prior authorization [form] - drug benefits
• Procedure for denial of benefits [internal review]
• Profiling
• Prompt payment of claims, interest, penalty
• Provider directory requirements
• Recoupment
• Rental network
• Required contract provisions
• Requirements for carriers and participating providers
• Retaliation
• Retroactive adjustments
• Second opinion
• Selection standards/reconsideration
• Standard I.D. cards
• Step therapy
• Telehealth
• Telemedicine
• Termination of contract
• Tiering
• Timely Payment
• Transparency of charges by health care providers
• Uniform credentialing application
• Utilization review