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REFERENCE TITLE: insurers; health providers; claims mediation |
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State of Arizona Senate Fifty-third Legislature First Regular Session 2017
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SB 1441 |
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Introduced by Senators Lesko: Allen S, Bowie, Fann, Worsley, Yee
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AN ACT
Amending title 20, Arizona Revised Statutes, by adding chapter 17.1; relating to health care insurance claims.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 20, Arizona Revised Statutes, is amended by adding chapter 17.1, to read:
CHAPTER 17.1
OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
ARTICLE 1. GENERAL PROVISIONS
20-2851. Definitions
In this chapter, unless the context otherwise requires:
1. "Administrator" means the claims administrator for the health benefit plan.
2. "Chief administrative law judge" means the chief administrative law judge of the office of administrative hearings.
3. "Department" means the department of insurance.
4. "Director" means the director of the department.
5. "Enrollee" means an individual who is eligible to receive benefits through a health care services plan.
6. "Facility" means a licensed health care institution in this state.
7. "Health care provider" means a person who is licensed, registered or certified as a health care professional under title 32 or a laboratory, durable medical equipment provider or other health care service provider that furnishes services to a patient in a network facility and separately bills the patient for the services.
8. "Health care services plan" means an individual or group plan offered by a disability insurer, group disability insurer, blanket disability insurer, hospital service corporation or medical service corporation under which the financing and delivery of health care services are provided, in whole or in part, through a defined set of providers under contract with the insurer.
9. "Insurer" means a disability insurer, group disability insurer, blanket disability insurer, hospital service corporation or medical service corporation.
10. "Mediation" means a process in which an impartial mediator facilitates and promotes agreement between the insurer offering a preferred provider benefit plan or the administrator and a health care provider or the health care provider's representative to settle an enrollee's health benefit claim.
11. "Mediator" means an impartial person who is appointed to conduct a mediation under this chapter.
12. "Network facility" means a facility that is a member of an insured's health care services plan network.
13. "Party" means an insurer offering a health care services plan or a health care provider or the health care provider's representative who participates in a mediation conducted under this chapter. Party includes an enrollee.
14. "Preferred provider" means a health care provider that is licensed to furnish health care services in this state or an organization of physicians or health care providers that contract with the insurer to provided covered services under a health care services plan.
15. "Surprise out-of-network bill" means a bill for any medical service performed at a network facility by a health care provider that is not a preferred provider if the insured did not know that the health care provider that was performing the service was not a preferred provider or a preferred provider was not available and it was impractical to wait for a preferred provider and the patient did not knowingly elect to obtain an out‑of‑network service.
20-2852. Applicability of chapter; remedies
A. This chapter applies to health care services plans and health care providers.
B. The remedies provided by this chapter are in addition to any other defense, remedy or procedure provided by law.
C. This chapter does not prohibit either:
1. An insurer that offers a health care services plan from, at any time, offering a reformed claim settlement.
2. A health care provider from, at any time, offering a reformed charge for medical services.
D. This chapter does not apply to limited benefit coverage as defined in section 20‑1137.
20-2853. Mandatory mediation
A. An enrollee may request mediation of a settlement of an out‑of‑network health benefit claim if all of the following apply:
1. The amount for which the enrollee is responsible to a health care provider, after copayments, deductibles and coinsurance, including the amount unpaid by the insurer, is greater than one thousand dollars.
2. The out-of-network health benefit claim is for a medical service or supply provided by a health care provider in a facility that is a preferred provider.
3. The enrollee received a surprise out-of-network bill.
B. Except as provided in subsections C and D of this section and notwithstanding section 20‑3102, if an enrollee requests mediation under this section, the health care provider or the health care provider's representative and the insurer shall participate in the mediation.
C. Except in the case of an emergency and if requested by the enrollee, a health care provider, before providing a medical service or supply, shall provide a complete disclosure to an enrollee that includes all of the following:
1. Explains that the health care provider does not have a contract with the enrollee's health care services plan.
2. Discloses the projected amounts for which the enrollee may be responsible.
3. Discloses the circumstances under which the enrollee would be responsible for those amounts.
D. A health care provider that makes a disclosure under subsection C of this section and that obtains the enrollee's written acknowledgment of that disclosure may not be required to mediate a billed charge under this section if the amount billed is less than or equal to the maximum amount projected in the disclosure.
20-2854. Mediator qualifications
A. Except as provided in subsection B of this section, to qualify for an appointment as a mediator under this chapter a person shall have completed at least forty classroom hours of training in dispute resolution techniques in a course conducted by an alternative dispute resolution organization or another dispute resolution organization approved by the chief administrative law judge.
B. A person who is not qualified under subsection A of this section may be appointed as a mediator on agreement of the parties.
C. A person may not act as mediator for a claim settlement dispute if the person has been employed by, consulted for or otherwise had a business relationship with an insurer offering the health care services plan or a health care provider during the three years immediately preceding the request for mediation.
20-2855. Appointment of mediator; fees
A. One mediator shall conduct a mediation.
B. The chief administrative law judge shall appoint the mediator through a random assignment from a list of qualified mediators that is maintained by the office of administrative hearings.
C. Notwithstanding subsection B of this section, a person other than a mediator who is appointed by the chief administrative law judge may conduct the mediation on agreement of all of the parties and shall provide notice to the chief administrative law judge of the change in mediator.
D. The mediator's fees shall be split evenly and paid by the insurer and the health care provider.
20-2856. Mandatory mediation; request; procedures
A. An enrollee may request mandatory mediation under this chapter.
B. A request for mandatory mediation shall be provided to the department on a form prescribed by the director and shall include:
1. The name of the enrollee who is requesting mediation.
2. A brief description of the claim to be mediated.
3. Contact information, including a telephone number, for the requesting enrollee and the enrollee's counsel, if the enrollee retains counsel.
4. The name of the health care provider and name of the insurer.
5. Any other information the director may require by rule.
C. On receipt of a request for mediation, the department shall notify the health care provider and the insurer of the request.
D. In an effort to settle the claim before mediation, all parties shall participate in an informal settlement teleconference within thirty days after the date on which the enrollee submits a request for mediation.
E. A dispute to be mediated under this chapter that does not settle as a result of a teleconference conducted under subsection D of this section shall be conducted in the county in which the medical services were rendered.
F. The enrollee may elect to participate in the mediation. A mediation may not proceed without the consent of the enrollee. An enrollee may withdraw the request for mediation at any time before the mediation.
G. Notwithstanding subsection F of this section, mediation may proceed without the participation of the enrollee or the enrollee's representative if the enrollee or the enrollee's representative is not present in person or through teleconference.
20-2857. Mediation; confidentiality
A. A mediator may not impose the mediator's judgment on a party about an issue that is a subject of the mediation.
B. A mediation session is under the control of the mediator.
C. Except as otherwise provided in this chapter, the mediator shall hold in strict confidence all information provided to the mediator by a party and all communications of the mediator with a party.
D. If the enrollee is participating in the mediation in person, at the beginning of the mediation, the mediator shall inform the enrollee that if the enrollee is not satisfied with the mediated agreement, the enrollee may file a complaint with any of the following:
1. The appropriate agency or health care regulatory board against the health care provider for improper billing.
2. The department for unfair claim settlement practices.
E. A party shall have an opportunity during the mediation to speak and state the party's position.
F. Except on the agreement of the participating parties, a mediation may not last more than four hours.
G. Except on the request of an enrollee, a mediation shall be held within one hundred eighty days after the date of the request for mediation.
H. Notwithstanding any other law, on receipt of notice from the department that an enrollee has made a request for mediation that meets the requirements of this chapter, the health care provider may not pursue any collection effort against that enrollee for copayments, deductibles and coinsurance before the earlier of:
1. The date the mediation is completed.
2. The date the request to mediate is withdrawn.
I. A service provided by a health care provider may not be summarily disallowed. This subsection does not require an insurer to pay for an uncovered service.
J. A mediator may not testify in a proceeding, other than a proceeding to enforce this chapter, related to the mediation agreement.
20-2858. Matters agreed in mediation
A. In a mediation under this chapter, the parties shall evaluate whether:
1. The amount charged by the health care provider for the medical service or supply is excessive.
2. The amount paid by the insurer represents the usual and customary rate for the medical service or supply or is unreasonably low.
B. Notwithstanding the determinations made in mediation or by a special master under this chapter, the enrollee is responsible only for the enrollee's copayments, deductibles and coinsurance.
C. The health care provider may present information regarding the amount charged for the medical service or supply. The insurer may present information regarding the amount paid by the insurer.
D. This chapter does not prohibit mediation of more than one claim between the parties during a mediation.
E. The goal of the mediation is to reach an agreement among the enrollee, the health care provider and the insurer as to the amount paid by the insurer to the health care provider and the amount charged by the health care provider.
20-2859. Resolution; no agreement; special master
A. The mediator of an unsuccessful mediation under this chapter shall report the outcome of the mediation to the department, the appropriate agency or health care regulatory board of the health care provider and the chief administrative law judge.
B. The chief administrative law judge shall enter an order of referral of a matter reported under subsection A of this section and appoint a special master. the order shall:
1. Name the special master on whom the parties agree or appoint a special master if the parties did not agree on a special master.
2. State the issues to be referred and the time and place on which the parties agree for the trial.
3. Require each party to pay the party's proportionate share of the special master's fee.
4. Certify that the parties have waived the right to trial by jury.
C. A trial by the special master who is selected or appointed pursuant to subsection B of this section shall proceed and the powers of the special master are those granted under rule 53, Arizona rules of civil procedure. The special master's verdict is not relevant or material to any other out‑of‑network claim dispute and has no precedential value.
20-2860. Continuation of mediation
After a referral is made pursuant to section 20‑2859, the health care provider and the insurer may elect to continue the mediation to further determine their responsibilities. Continuation of mediation under this section does not affect the amount of the billed charge to the enrollee.
20-2861. Mediation agreement
A. The mediator shall prepare a confidential mediation agreement and order that states any agreement reached by the parties pursuant to section 20‑2860.
B. The mediator shall report to the director and the appropriate agency or health care regulatory board:
1. The names of the parties to the mediation.
2. Whether the parties reached an agreement or the mediator made a referral under section 20‑2859.
20-2862. Bad faith mediation; administrative penalties
A. The following conduct constitutes bad faith mediation for purposes of this chapter:
1. Failing to participate in the mediation.
2. Failing to provide information the mediator believes is necessary to facilitate an agreement.
3. Failing to designate a representative participating in the mediation with full authority to enter into any mediated agreement.
B. Failure to reach an agreement is not conclusive proof of bad faith mediation.
C. A mediator shall report bad faith mediation to the department or the appropriate agency or health care regulatory board of the health care provider, as appropriate, following the conclusion of the mediation.
D. Bad faith mediation by a party other than the enrollee is grounds for imposition of an administrative penalty by the regulatory agency that issued a license, certificate or certificate of authority to the party who committed the violation.
E. Except for good cause shown, on a report of a mediator and appropriate proof of bad faith mediation, the regulatory agency that issued the license, certificate or certificate of authority shall impose an administrative penalty.
20-2863. Consumer protection; rules
A. The director and the agency or the health care regulatory boards that license, certify or register health care providers shall adopt rules regulating the investigation and review of a complaint filed that relates to the settlement of an out‑of‑network health care services plan claim that is subject to this chapter. The rules adopted under this section shall:
1. Distinguish among complaints for out‑of‑network coverage or payment and give priority to investigating allegations of delayed medical care.
2. Develop a form for filing a complaint and establish an outreach effort to inform enrollees of the availability of the claims dispute resolution process under this chapter.
3. Ensure that a complaint is not dismissed without appropriate consideration.
4. Ensure that enrollees are informed of the availability of mandatory mediation.
B. The department and the appropriate agency or health care regulatory board shall maintain information:
1. On each complaint filed that concerns a claim or mediation subject to this chapter.
2. Related to a claim that is the basis of an enrollee complaint, including:
(a) The type of services that gave rise to the dispute.
(b) The type and specialty, if applicable, of the health care provider who provided the out-of-network service and the surprise out‑of‑network bill.
(c) The county and metropolitan area in which the medical service or supply was provided.
(d) Whether the medical service or supply was for emergency care.
(e) Any other information about:
(i) The insurer that the director by rule requires.
(ii) the health care provider that the agency or health care regulatory board by rule requires.
C. The information collected and maintained by the department and the agency and health care regulatory boards under subsection B, paragraph 2 of this section is public information and may not include personally identifiable information or medical information.
D. The chief administrative law judge shall adopt rules relating to mediation and appointment of a special master pursuant to this chapter.
E. A health care provider that fails to provide a disclosure under section 20‑2853 is not subject to discipline by the agency or health care provider's regulatory board for that failure and a cause of action is not established by a failure to disclose as required by section 20‑2853.
Sec. 2. Effective date
This act is effective from and after December 31, 2017.