Report Title:

Relating to thge patients' Bill of Rights and responsibilities act.

Description:

Provides for an external review process in health insurance coverage decisions that would not be pre-empted by ERISA.

THE SENATE

S.B. NO.

772

TWENTY-THIRD LEGISLATURE, 2005

  

STATE OF HAWAII

  

 

A BILL FOR AN ACT

 

RELATING TO THE PATIENTS′ BILL OF RIGHTS AND RESPONSIBILITIES ACT.

 

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

SECTION 1. Section 432E-6, Hawaii Revised Statutes, is amended to read as follows:

"§432E-6 External review procedure. (a) [After exhausting all internal complaint and appeal procedures available, an enrollee, or the enrollee's treating provider or appointed representative, may file a request for external review of a managed care plan's final internal determination to a three-member review panel appointed by the commissioner composed of a representative from a managed care plan not involved in the complaint, a provider licensed to practice and practicing medicine in Hawaii not involved in the complaint, and the commissioner or the commissioner's designee in the following manner:

(1) The enrollee shall submit a request for external review to the commissioner within sixty days from the date of the final internal determination by the managed care plan;

(2) The commissioner may retain:

(A) Without regard to chapter 76, an independent medical expert trained in the field of medicine most appropriately related to the matter under review. Presentation of evidence for this purpose shall be exempt from section 91-9(g); and

(B) The services of an independent review organization from an approved list maintained by the commissioner;

(3) Within seven days after receipt of the request for external review, a managed care plan or its designee utilization review organization shall provide to the commissioner or the assigned independent review organization:

(A) Any documents or information used in making the final internal determination including the enrollee's medical records;

(B) Any documentation or written information submitted to the managed care plan in support of the enrollee's initial complaint; and

(C) A list of the names, addresses, and telephone numbers of each licensed health care provider who cared for the enrollee and who may have medical records relevant to the external review;

provided that where an expedited appeal is involved, the managed care plan or its designee utilization review organization shall provide the documents and information within forty-eight hours of receipt of the request for external review.

Failure by the managed care plan or its designee utilization review organization to provide the documents and information within the prescribed time periods shall not delay the conduct of the external review. Where the plan or its designee utilization review organization fails to provide the documents and information within the prescribed time periods, the commissioner may issue a decision to reverse the final internal determination, in whole or part, and shall promptly notify the independent review organization, the enrollee, the enrollee's appointed representative, if applicable, the enrollee's treating provider, and the managed care plan of the decision;

(4) Upon receipt of the request for external review and upon a showing of good cause, the commissioner shall appoint the members of the panel and shall conduct a review hearing pursuant to chapter 91. If the amount in controversy is less than $500, the commissioner may conduct a review hearing without appointing a review panel;

(5) The review hearing shall be conducted as soon as practicable, taking into consideration the medical exigencies of the case; provided that:

(A) The hearing shall be held no later than sixty days from the date of the request for the hearing; and

(B) An external review conducted as an expedited appeal shall be determined no later than seventy-two hours after receipt of the request for external review;

(6) After considering the enrollee's complaint, the managed care plan's response, and any affidavits filed by the parties, the commissioner may dismiss the request for external review if it is determined that the request is frivolous or without merit; and

(7) The review panel shall review every final internal determination to determine whether the managed care plan involved acted reasonably. The review panel and the commissioner or the commissioner's designee shall consider:

(A) The terms of the agreement of the enrollee's insurance policy, evidence of coverage, or similar document;

(B) Whether the medical director properly applied the medical necessity criteria in section 432E-1.4 in making the final internal determination;

(C) All relevant medical records;

(D) The clinical standards of the plan;

(E) The information provided;

(F) The attending physician's recommendations; and

(G) Generally accepted practice guidelines.

The commissioner, upon a majority vote of the panel, shall issue an order affirming, modifying, or reversing the decision within thirty days of the hearing.

(b) The procedure set forth in this section shall not apply to claims or allegations of health provider malpractice, professional negligence, or other professional fault against participating providers.

(c) No person shall serve on the review panel or in the independent review organization who, through a familial relationship within the second degree or consanguinuity or affinity, or for other reasons, has a direct and substantial professional, financial, or personal interest in:

(1) The plan involved in the complaint, including an officer, director, or employee of the plan; or

(2) The treatment of the enrollee, including but not limited to the developer or manufacturer of the principal drug, device, procedure, or other therapy at issue.

(d) Members of the review panel shall be granted immunity from liability and damages relating to their duties under this section.

(e) An enrollee may be allowed, at the commissioner′s discretion, an award of a reasonable sum for attorney′s fees and reasonable costs incurred in connection with the external review under this section, unless the commissioner in an administrative proceeding determines that the appeal was unreasonable, fraudulent, excessive, or frivolous.

(f) Disclosure of an enrollee's protected health information shall be limited to disclosure for purposes relating to the external review.]

The commissioner shall provide a mechanism for the external review of a managed care plan decision when there is a dispute between the treating physician or the enrollee and the managed care plan regarding:

(1) Whether the disputed service, supply or treatment is covered under the terms of the enrollee's insurance policy, evidence of coverage, or similar document; and

(2) If applicable, whether the disputed service, supply or treatment proposed by the treating physician meets the medical necessity criteria in 432E-1.4(b) under the terms of the agreement or the enrollee's insurance policy, evidence of coverage, or similar document.

The external review shall be conducted by an independent review organization that is selected by the commissioner and that has no corporate affiliation with the managed care plan under review. In the event that the independent review organization determines that the covered service, supply, or treatment is medically necessary or that the service, supply or treatment is covered under the terms of the enrollee's insurance policy, evidence of coverage, or similar document, the managed care plan shall provide the service, supply or treatment. The independent review organization may either affirm or reverse the final internal determination.

(b) After exhausting all internal complaint and appeal procedures available, an enrollee, the enrollee's treating physician, or the enrollee's appointed representative may file a request with the commissioner for an external review under this section. The request for external review shall be received by the commissioner no later than sixty days from the date of the final internal determination by the managed care plan.

(c) Within seven days after receipt of the request for external review, the managed care plan shall provide to the commissioner two copies of:

(1) Any documents or information used in making the final internal determination including the enrollee's medical records and the document describing the enrollee's benefits;

(2) Any documentation or written information submitted to the managed care plan in support of the enrollee's initial complaint;

(3) An estimate of the amount in controversy; and

(4) A list of the names, addresses, and telephone numbers of each licensed health care provider who cared for the enrollee and who may have medical records relevant to the external review;

provided that where an expedited appeal is involved, the managed care plan shall provide the documents and information within forty-eight hours of receipt of the request for external review. Failure by the managed care plan to provide the documents and information within the prescribed time periods shall not delay the conduct of the external review. Where the managed care plan fails to provide the documents and information within the prescribed time periods, the commissioner may issue a decision to reverse the final internal determination, in whole or part, and shall promptly notify the enrollee and the managed care plan of the decision.

(d) After considering the enrollee's complaint, the managed care plan's response, and the available record, the commissioner may dismiss the request for external review if the commissioner determines that the request is frivolous, without merit, not for good cause, or does not fall within the scope of the disputes described in subsection (a).

(e) The decision of the independent review organization shall be made no later than sixty days after the date of the request for the external review. The independent review organization shall send a copy of the decision to the enrollee or the enrollee's representative, the managed care plan, and the commissioner within thirty days of the decision. The decision of the independent review organization shall be final and shall not be subject to appeal.

(f) When determining medical necessity or other issues where the independent review organization determines that medical expertise is necessary, the independent review organization shall use a physician with expertise in the relevant medical field to make the determination. An expert reviewer assigned by an independent review organization or the independent review organization selected by the commissioner shall not have a direct professional, familial, or financial interest in or conflict of interest with any of the following:

(1) The managed care plan, that is the subject of the external review;

(2) Any officer or director of the managed care plan, that is the subject of the external review;

(3) The treating physician who proposes to render or provide the service, supply or treatment that is the subject of the external review;

(4) The health care facility at which the service, supply or treatment was provided or will be provided;

(5) The developer or manufacturer of the supply, that is, the principal drug, device, procedure, or other therapy that is being proposed for the enrollee; or

(6) The enrollee.

(g) The managed care plan that is the subject of the external review shall be responsible for paying the reasonable expenses of the independent review organization selected by the commissioner to conduct the review.

(h) The external review procedure set forth in this section shall not apply to claims or allegations of health provider malpractice, professional negligence, or other professional fault against participating providers.

(i) Disclosure of an enrollee's protected health information shall be limited to disclosure necessary for purposes relating to the external review.

(j) Future contractual or employment action by the managed care plan regarding the treating physician or dentist shall not be based on that physician's participation in the external review process."

SECTION 2. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 3. This Act shall take effect on October 1, 2005.

INTRODUCED BY:

_____________________________

BY REQUEST