BILL REQ. #:  H-3823.1 

Read first time 01/17/2006.   Referred to Committee on Health Care.

     AN ACT Relating to health care provider contracts; and adding a new section to chapter 48.43 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   A new section is added to chapter 48.43 RCW to read as follows:
     (1) Every contract between a health care provider or facility and a health carrier, an insurer, or other organization engaged in the business of creating provider networks must conform to the provisions of this section and rules adopted by the commissioner governing such contracts. For the purpose of this section, "contractor" refers to health carriers, insurers, and other organizations engaged in the business of creating provider networks.
     (2) Irrespective of any other remedy for violation of the provisions of this section, a provider or facility contract that is subject to this section and that fails to contain or otherwise conflicts with the provisions of this section must be interpreted as though the contract contained or conformed to provisions of this section.
     (3) Every provider contract must contain a "locum tenens" provision that permits a contracted provider to select another licensed provider who will serve in place of the contracted provider when the contracted provider is temporarily unavailable to provide health care services. The contracted provider need not select a substitute provider then under contract with the contractor but the contractor may reject any provider failing to meet the basic credentialing standards of the contractor. The provider must notify the contractor of the substitution in a reasonable time period and the substitute provider is subject to the same terms and conditions as the absent, contracted provider. The contractor may limit the time period of substitution to sixty consecutive days in any one period of substitution.
     (4) No contractor may directly or indirectly require a provider to participate in all plans, programs, and health care arrangements as a condition for participating in any of the contractor's other plans, programs, or health care arrangements. For example and not as a limitation of this subsection, a contractor may not require a provider who has agreed to furnish care to enrollees of a health plan to also participate in a discount program for uninsured health care services or to participate in a property casualty insurance program.
     (5) Every provider contract must contain procedures for an independent, outside review of billing disputes. The costs for the review must be borne by the provider if the independent review substantially upholds the contractor's decision and by the contractor if the review substantially overturns the contractor's decision. The commissioner shall adopt rules governing procedures for independent review of the billing disputes.
     (6)(a) Initially upon contracting, upon the provider's or facility's written request and annually thereafter on or before the contract anniversary date, a contractor shall disclose to contracted providers and facilities the following information in an electronic format (or in writing, if agreeable to both parties):
     (i) The complete fee schedule for the type of contracting provider or facility; and
     (ii) The detailed compensation policies and payment rules used to adjudicate claims, which must, unless otherwise prohibited by state law:
     (A) When available, be consistent with current procedural terminology and national medicare guidelines;
     (B) Clearly and accurately state what is covered by any global payment provisions for both professional and institutional services, any global payment provisions for all services necessary as part of a course of treatment in an institutional setting, and any other global arrangements such as per diem hospital payments; and
     (C) At a minimum, clearly and accurately state the policies regarding: Reimbursement for multiple procedures, reimbursement for assistant providers, recognition of current procedural terminology modifiers, and bundling of current procedural terminology codes.
     (b) The contractor may limit redisclosure of payment information only as necessary to protect proprietary information.