H.
B.
4661
(By Delegates Petersen, Huntwork and Leach)
[Introduced March 2, 1994; referred to the
Select Committee on Health Care Policies then Finance.]
A BILL to amend chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, by adding thereto a new article, designated article twenty-nine-e, relating to utilization review of health care providers; purpose; definitions; general requirements; and appeals for all utilization review programs.
Be it enacted by the Legislature of West Virginia:
That chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended by adding thereto a new article, designated article twenty-nine-e, to read as follows:
ARTICLE 29E. UTILIZATION HEALTH CARE REVIEW
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16-29E-1. Purposes.
The purposes of this article are to:
(a) Promote the delivery of quality health care in a cost effective manner;
(b) Foster greater coordination between health care providers, third-party payors and others who conduct utilization review activities; and
(c) Protect patients, employers and health care providers by ensuring that utilization review activities result in informed decisions on the appropriateness of medical care made by those best qualified to be involved in the utilization review process.
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16-29E-2. Definitions.
For purposes of this article:
(a) "Health care provider" means any person, corporation, facility or institution licensed by this state to provide or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist or psychologist and officer, employee or agent of such provider acting in the course and scope of his employment or agency related to or supportive of health care services;
(b) "Health care services" means acts of diagnosis, treatment, medical evaluation or advice or such other acts as may be permissible under the health care licensing statutes of this state;
(c) "Physician" means an individual licensed to practice medicine in all of its branches;
(d) "Utilization review" means a prospective, concurrent or retrospective review of the medical necessity of health care services provided, or proposed to be provided, to a patient or group of patients for the purpose of recommending or determining whether such services should be covered or provided by an insurer, plan or other entity or persons;
(e) "Utilization review agent" means any person or entity engaged in the conduct of utilization review other than general in-house hospital review activities.
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16-29E-3. Conduct of utilization review; general requirements.
Any program of utilization review with regard to hospital, medical or other health care services provided in this state shall comply with the following general requirements:
(a) Physicians shall be compensated for complying with utilization review requirements that are more costly, complex and time consuming than standard health insurance claim forms, such as requirements for obtaining preadmission certification, second opinions on elective surgery and certification for extended length of stay.
(b) During prospective, concurrent and retrospective review, utilization review agents may only collect the information required to certify the admission, procedure, and/or length of stay. They may request, but not require, encoded diagnoses or procedures. They may not routinely request copies of medical records and they shall reimburse providers for the reasonable costs of duplicating any records requested.
(c) Concurrent review is conducted on a patient on an "as needed" basis and may not routinely include daily review. Onsite and telephone review may be conducted only during hospitals and physicians' reasonable and normal business hours unless otherwise mutually agreed.
(d) Utilization review agents are required to share all available clinical and demographic information among their staff to avoid duplicate requests for information from providers or enrollees.
(e) All utilization review agents shall obtain certification from the insurance commissioner. Such certification shall include provisions for application, fees and annual renewal. To obtain certification, the utilization review agent shall comply with the following requirements:
(1) Make utilization review staff available via toll-free telephone access during normal working hours and have telephone messaging systems available to accept incoming calls at other times;
(2) Respond to patient or physician requests for prior authorization of service within two business days;
(3) Make qualified personnel available during normal business hours for same-day telephone response to inquiries about medical necessity, including certification of continued length of stay;
(4) If additional information is required to make a decision in relation to a request for coverage or payment, respond to such request within two business days of the receipt of any such additional information;
(5) Allow at least two working days for notification of emergency admission and request for continued stay authorization;
(6) Provide a written policy to ensure protection of confidentiality;
(7) Provide a written quality assurance/quality control plan;
(8) Agree to abide by mutually agreed upon authorization practices developed with the provider in the conduct of onsite utilization review;
(9) Screen criteria, weight elements, computer algorithms or other guidelines, including, but not limited to, care plans or critical pathways, utilized in the review process and release their method of development and approval, to physicians upon request at a reasonable cost;
(10) Notify the enrollee and provider of record of review decisions within two business days:
Provided,
That a provider and utilization review agent may mutually agree to a process of allowing hospital staff to forward notifications of negative determinations made for continuation of inpatient services to the patient or his or her representative if the patient is an inpatient when the determination is made;
(11) Make no determination adverse to a patient or to any affected health care provided on any questions relating to the necessity or justification for any form of hospital, medical or other health care services without prior evaluation and concurrence in the adverse determination by a physician;
(12) Include in any notice of determination regarding hospital, medical or other health care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial or precertification for that service the evaluation, findings, and concurrence of a physician, as such term is defined in section 1861 (r) (1) of the Social Security Act, licensed to practice medicine in the jurisdiction from which the claim arose and trained in the relevant specialty or subspecialty pertinent to the services under review. Such notice shall also include the reasons for the adverse determination along with the appeal procedures to be followed if the patient or provider disagrees with the decision;
(13) Make expedited appeal requests available to the attending physician, patient, or hospital representatives when there is a denial of ongoing or proposed service:
Provided,
That expedited appeals shall be accomplished within forty-eight hours of the date of appeal and receipt of all information:
Provided,
however,
That expedited appeals not resolving an issue may be resubmitted through regular process;
(14) Complete regular, nonexpedited appeals within thirty days:
Provided,
That any appeal determination whether expedited or nonexpedited, which concerns hospital, medical or other health care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings, and concurrence of a physician, as such term is defined in section 1861 (r) (1) of the Social Security Act, licensed to practice medicine in the jurisdiction from which the claim arose and trained in the relevant specialty or subspecialty pertinent to the services under review;
(15) Ensure all determinations are reviewed by a physician or are in accordance with standards that are established by a physician;
(16) Disallow utilization review agents or employees compensation to be based on the number of adverse determinations made or the amount of claim reduction achieved through the utilization review process.
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16-29E-4. Appeals.
All utilization review determinations are appealable. The insurance commissioner shall designate administrative law judges to hear any such appeals in compliance with the administrative procedures act as set forth in chapter twenty-nine-a of this code.
NOTE: This bill is intended to create a health care utilization review process in order to promote cost effective delivery of health care by health care providers. The bill contains the following provisions: Purposes; definitions; general requirements; and provides for an appeals process of all utilization review determinations.
This article is new; therefore, strike-throughs and underscoring have been omitted.