Colorado
Insurance Information
INSURANCE
QUESTIONS???
Contact CCA Insurance Committee Chair Dr. Greg Crawford at
greglcrawforddc@aol.com
- or 970-493-8386
Implications of SB79 Standard Contract Bill
SB 79 will reduce
administrative costs
associated with processing multiple payer contracts, all of which have
different language and conditions. It
ensures that all contracts are drafted in plain language and use set of
terms. The bill requires payers to notify
providers of changes and updates to their contracts.
Previously, payers might make changes which
providers might to be aware of, and those added conditions had a
negative
impact. If someone from the office did
not regularly check a payer’s web site, they would be unaware of
material
changes to their contract. After January
1, 2008, providers are no longer obligated to accept unilateral changes
made by
the plans during the term of their contract. This
will bring transparency to the contracting
process. It
eliminates “contracts of
adhesion” that all doctors are required to sign when they join a
managed care
network. The law will eliminate “phantom” networks, stop
retroactive
contract changes, require that a copy of the fee schedule be attached
to the
contract, and provide other helpful contractual provisions that will
allow you to
evaluate whether to sign the contract or get out of the network.
SB 79, as set forth in the
bill summary,
requires any
person or
entity contracting with a health care provider on or after
January 1, 2008, to use
a standard form contract . Requires each contract to include a summary
disclosure form that contains:
- Compensation and payment
terms that are sufficient for the health care provider to identify the
compensation for health care that is provided that shall include a fee
schedule;
- The duration of the
contract and reasonable termination terms;
- The identity of the
claims processors;
- Dispute resolution terms;
and
- The subject and order of
an addenda, if applicable.
Requires the person or
entity to identify a program
used to review, monitor, evaluate, or assess the health care services
provided.
Exempts a person or entity from providing a fee schedule to a provider
if the
fee schedule is for dental services whose providers include licensed
dentists,
and the fee schedule is based on fees filed by the dental provider and
is
revised periodically.
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Requires the person or
entity to state how a
completed claim was adjudicated and any outstanding balance owed.
Requires the
payment and compensation terms to be disclosed in writing when a
contract is
proposed by the person or entity. Allows
a material change to a contract only if the change is provided in
writing 90
days prior to the change. Allows a contract to be terminated by either
party if
there is written objection to the change, unless the objection is to an
addition of a new category of coverage. Prohibits a person or entity
from
assigning, allowing access to, selling, renting, or giving the rights
to the
provider's services unless specific conditions are met. Prohibits a
contract
from requiring a waiver of the provider's legal rights as a condition
of
entering into the contract. Allows a
health care provider to decline services to new patients upon 60 days'
notice.
Allows for termination of a contract without cause
by either party if the
contract is for less than 2
years, otherwise requires the termination without cause terms to be
specified
in the contract. Exempts certain entities from the requirement of using
the
contract. Allows a contract to include
an agreement for binding arbitration.
Requires the availability
of private rights of
action, equitable relief, reasonable attorney fees when the provider is
the
prevailing party in an action, and the option to introduce prior
arbitration
awards regarding a violation.
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