Promoting health plan reform
by Susan Koontz, JD, CMS General Counsel
The Colorado Medical Society’s main focus in the 2017 legislative session is to promote health plan reform to salvage the deteriorating practice environment and remove patient hurdles to care. Physicians understand all too well the impact of health insurance mergers: the balance is skewed to put all the power in the hands of very few health plans. There is no market competition because of the concentration of power and physicians are forced to accept take-it-or-leave-it contracts.
Practices and patients already face prior authorization and payment nightmares, and patients are losing their physicians due to narrowing networks with increasing physician deselections from networks without a clear explanation or appeal right as health plans chase the lowest cost point.
There is no transparency by health plans regarding payment for out-of-network charges, with a pattern of the insurers using fraudulent databases to set rates. This history of fraud deteriorates trust of health plans; they must use an independent database. And the scant regulatory enforcement is biased in favor of the health plans.
There are six issues for which CMS will advocate legislation to address these grave concerns.
Issue 1: Out of network (OON) and surprise bills
- Establish a fair and transparent solution to the OON network “surprise bills” issue.
- Put a shared and fair responsibility for notifying patients on the facility, OON provider and health plan.
- Protect consumers from balance billing.
- Establish a fair reimbursement rate for providers.
- Set up a due process appeal for OON physicians to challenge “unfair reimbursement rates.”
Issue 2: DOI complaints and dispute resolution
- Require the commissioner of the Division of Insurance to investigate and resolve complaints from physicians regarding claim mishandling and inappropriate denials.
- Include provider complaints in the annual report to the legislators.
- Authorize the commissioner to financially penalize a health plan for a pattern of abuse.
Issue 3: Selection/de-selection: Notification of patients and providers, transparent standards, appeal rights, the “Keep Your Physician” bill
- Require transparency and fairness in health plans’ network construction (selection/de-selection process) and in the development of tiered networks.
- Require health plans to communicate to physicians its standards for de-selection/selection and tiering of networks.
- Require products identified as “value,” “high performing” or “quality” to have quality and not cost as the main criteria for selection/de-selection.
- Prohibit discrimination against physicians serving rural areas or who are treating chronically ill patients that may cause higher than average costs.
Issue 4: Mergers – transparency and independent investigations
For merger approvals, this bill would require foreign health plans (corporations formed in other states) to publicly disclose the Form E (the anticompetitive analysis conducted by the plan) and would require the DOI to conduct public hearings concerning the anticompetitive effects of the proposed merger.
Issue 5: Protection from retaliation
A bill on this issue would require the DOI commissioner to impose penalties for health plans engaging in patterns of abuse in retaliation for physicians informing regulators or legislators about the problems and concerns they face when dealing with health plans.
Issue 6: Making telehealth work
This bill aims to clarify the intent of the 2015 telehealth law. Health plans are interpreting the 2015 law to require physicians to use each health plan’s different telehealth vendors, forcing physicians to contract with numerous vendors and raising cost of health care, which was never the intent of the 2015 law.
The first regular session of the 71st Colorado General Assembly convened on Jan. 11, 2017. Watch for more on these issues. We encourage physicians to stay involved with CMS during the session. We will need physicians to testify in support of any of these issues. Email firstname.lastname@example.org or call 720-858-6322 to express your interest in testifying.
Posted in: Colorado Medicine | Legislative Updates | Practice Evolution | Payment Reform | Interacting With Payers | Initiatives | Advocacy