COMMITTEE SUBSTITUTE
FOR
H. B. 2885
(By Delegates Perdue, Hatfield, Marshall,
Michael, Moore, Rodighiero and Border)
(Originating in the Committee on Finance)
[March 24, 2009]
A BILL to amend and reenact §16-1A-1, §16-1A-3 and §16-1A-4 of the
Code of West Virginia, 1931, as amended; and to amend said
code by adding thereto two new sections, designated §16-1A-5
and §16-1A-6, all relating to establishing a uniform
credentialing form and establishing a single Credentialing
Verification Organization (CVO) in the state; authorizing the
insurance commission and the Department of Health and Human
Services to put the CVO out for bid; establishing various
aspects of the CVO program; establishing time frames for
credentialing; requiring all health care practitioners and
insurers, hospitals, third party administrators and other
health care entities to use the CVO and the credentialing form
and continuing the advisory committee established to create
the credentialing form and to provide a review of the CVO and
make recommendations for improvement.
Be it enacted by the Legislature of West Virginia:
That §16-1A-1, §16-1A-3 and §16-1A-4 of the Code of West Virginia, as amended, be amended and reenacted; and that said code
be amended by adding thereto two new sections, designated §16-1A-5
and §16-1A-6, all to read as follows:
ARTICLE 1A. UNIFORM CREDENTIALING FOR HEALTH CARE PRACTITIONERS.
§16-1A-1. Legislative findings; purpose.
(a) The Legislature finds:
(1) Credentialing, required by hospitals, insurance companies,
prepaid health plans, third party administrators and other health
care entities, is necessary to assess and verify the education,
training, experience and
current clinical competence of health care
practitioners to ensure that qualified professionals treat the
citizens of this state.
(2) Currently,
a each of the entities requiring credentialing
has its own credentialing application
forms form resulting in
health care practitioners being required to complete multiple forms
listing the same or similar information. The duplication is
costly, time consuming and not in the best interests of the
citizens of this state has been created to reduce duplication and
increase efficiency. Each health care entity performs primary
source verification for the practitioners who apply to that entity
for affiliation. This duplication of primary source verification
is time consuming and costly.
(3) The Secretary of the Department of Health and Human
Resources and the Insurance Commissioner share regulatory authority
over the entities requiring credentialing.
(b) The purpose of this article is to
authorize the
development of uniform credentialing application forms by those
public officials regulating the entities that require credentialing
and to
establish continue an the advisory committee to assist in
developing a uniform credentialing process and
implementing to
implement the use of uniform credentialing
through a single
credentialing verification organization in this state.
§16-1A-3. Advisory committee Definitions.
(a) The secretary of the department of health and human
resources and the insurance commissioner shall jointly establish an
advisory committee to assist them in the development and
implementation of the uniform credentialing process in this state.
The advisory committee shall consist of eleven appointed members.
Six members shall be appointed by the secretary of the department
of health and human resources: One member shall represent a
hospital with one hundred beds or less; one member shall represent
a hospital with more than one hundred beds; one member shall
represent another type of health care facility requiring
credentialing; one member shall be a person currently credentialing
on behalf of health care practitioners; and two of the members
shall represent the health care practitioners subject to
credentialing. Five members shall be representative of the
entities regulated by the insurance commissioner that require
credentialing and shall be appointed by the insurance commissioner:
One member shall represent an indemnity health care insurer; one member shall represent a preferred provider organization; one
member shall represent a third party administrator; one member
shall represent a health maintenance organization accredited by
American accreditation health care commission; and one member shall
represent a health maintenance organization accredited by the
national committee on quality assurance. The secretary of the
department of health and human resources and the insurance
commissioner, or the designee of either or both, shall be nonvoting
ex officio members.
(b) Of the members of the advisory committee first appointed,
four shall be appointed for a term of one year, four shall be
appointed for a term of two years, and three shall be appointed for
a term of three years. At the expiration of the initial terms,
successors will be appointed to terms of three years. Members may
serve an unlimited number of terms. When a vacancy occurs as a
result of the expiration of a term or otherwise, a successor of
like qualifications shall be appointed.
(c) The advisory committee shall meet at least annually to
review the status of uniform credentialing in this state, and may
make further recommendations to the secretary of the department of
health and human resources and the insurance commissioner as are
necessary to carry out the purposes of this article. Any uniform
forms and the list of health care practitioners required to use the
uniform forms as set forth in legislative rule proposed pursuant to
section two of this article may be amended as needed by procedural
rule.
(a) "Commission" is the Insurance Commission.
(b) "CVO" is a Credentialing Verification Organization which
verifies the professional qualifications of all practitioners that
are participating providers and that provide health care services
to consumers.
(c) "The department" is the Department of Health and Human
Resources;
(d) "Health care practitioners" means those established
pursuant to section two of this article in legislative rule.
(e) "Joint Commission" is an independent not-for-profit
organization that evaluates and accredits more than 15,000 health
care organizations and programs in the United States.
(f) "NCQA" means the National Committee for Quality Assurance,
which is a private, 501(c)(3) not-for-profit organization dedicated
to improving health care quality.
(g) "Primary source verification procedure" means the
procedure used by a credentialing organization to verify the
accuracy of documents and credentialing information submitted to it
by a health care practitioner who is applying for affiliation with
a health care entity.
(h) "URAC" means the American Accreditation Healthcare
Commission.
§16-1A-4. Report required Credentialing verification organization.
On or before the first day of January, two thousand two, the
Secretary of the Department of Health and Human Resources and the Insurance Commissioner shall jointly report to the Legislative
Oversight Commission on Health and Human Resources Accountability
on the need, if any, for further legislation to implement the use
of the uniform credentialing application forms developed pursuant
to the legislative rule authorized by section two of this article.
(a) The department and the commission are hereby given
exclusive authorization to execute such contracts as are necessary
to carry out the provisions of this article to provide a single CVO
in the state that will provide electronic access to the West
Virginia uniform credentialing application to all practitioners.
The initial contract shall be for a period of five years at which
time other credentialing organizations may enter the state. The
selected entity shall be the central repository for information
required by hospitals, and payers as part of the credentialing
process, will verify all information provided by the practitioner,
including site visits to the practitioner's office if required by
a health plan and will make this information available
electronically to hospitals, providers and all payers. The entity
will also establish procedures for ensuring that practitioners'
files are kept up to date by issuing quarterly reminders for
updated information.
The CVOs shall be given preference if organized within the
state of West Virginia. The CVOs are required to include on their
board representatives of those classes of entities who will be
using the CVO. The CVO shall develop a payment system that will cover the costs of the program and that is evaluated by the
advisory committee created in section five of this article prior to
implementation.
(b) The CVO shall maintain professional and general business
liability insurance for the protection of its clients in an amount
to be determined by the secretary and commissioner and included in
the request for proposal.
(c) Health care practitioners who are required to be
credentialed as well as hospitals, insurance companies, prepaid
health plans, managed care organizations, third party
administrators and other health care entities who credential their
employees shall utilize the services of a single CVO awarded a
contract by the department and the commission upon the
effectiveness of the CVO. This mandate shall not be effective
until and is premised upon:
(1) Each CVO being certified by the National Committee for
Quality Assurance (NCQA);
(2) Accreditation by URAC
(3) Demonstrated compliance with the principles for
credentialing verification organizations set forth by the Joint
Commission; and
(4) Demonstrated compliance with the Center for Medicare and
Medicaid Services Conditions of Participation (CoPs) and Conditions
for Coverage (CfCs) that health care organizations must meet in
order to begin and continue participating in the Medicare and
Medicaid programs.
(d) Each healthcare practitioner is required to use the
uniform credentialing application form developed by the advisory
committee. Each health care practitioner who is required to be
credentialed shall use the CVO created in this article.
(e) Each healthcare practitioner required to use the
credentialing verification organization shall be recredentialed
every two years on their birthday. Those born in odd years shall
be recredentialed in odd years and those born in even years shall
be recredentialed in even years. The CVO may make other
arrangements consistent with a health care entities' practices and
procedures.
(f) Each health care entity which requires credentialing shall
accept the credentialing application approved by the advisory
committee established in section four of this article.
(g) The CVO shall communicate by letter, fax or e-mail a
notice of receipt and a notice of any additional documents or
information needed to complete the application within twenty-one
days of receipt of the application. If the CVO receives any
information that is inconsistent with the information that the
health care professional provided, the CVO shall request that the
professionl provide clarification of the inconsistency.
(h) Each applicant shall be credentialed within sixty days or
no greater than ninety days of the application being deemed
complete. The application is deemed complete when all information
has been provided by the practitioner and all items have been
verified.
(i) If the insurance company takes more than the ninety days
to credential a health care practitioner, the insurer is liable
for either a civil penalty payable to the provider in the amount of
$500 a day, including weekend days. Additionally, starting at the
expiration of the ninety-day period until the credentialing is
either approved or denied the insurance company shall make
retroactive reimbursement to the provider for the services provided
from the expiration of the ninety-day period and up to the point at
which the health care professional is approved or denied. This
practice accrues whether or not the practitioner's credentials are
accepted by the insurer.
(j) In the additional process of granting privileges, the
hospital shall follow their own governing documents for granting
privileges.
§16-1A-5. Advisory committee.
(a) The Secretary of the Department of Health and Human
Resources and the Insurance Commissioner shall jointly establish an
advisory committee to assist them in the development and
implementation of the uniform credentialing process in this state.
The advisory committee shall consist of eleven appointed members.
Six members shall be appointed by the Secretary of the Department
of Health and Human Resources: One member shall represent a
hospital with one hundred beds or less; one member shall represent
a hospital with more than one hundred beds; one member shall
represent another type of health care facility requiring credentialing; one member shall be a person currently credentialing
on behalf of health care practitioners; and two of the members
shall represent the health care practitioners subject to
credentialing. Five members shall be representative of the
entities regulated by the Insurance Commissioner that require
credentialing and shall be appointed by the Insurance Commissioner:
One member shall represent an indemnity health care insurer; one
member shall represent a preferred provider organization; one
member shall represent a third party administrator; one member
shall represent a health maintenance organization accredited by
American accreditation health care commission; and one member shall
represent a health maintenance organization accredited by the
national committee on quality assurance. The Secretary of the
Department of Health and Human Resources and the Insurance
Commissioner, or the designee of either or both, shall be nonvoting
ex officio members.
(b) At the expiration of the initial terms, successors will be
appointed to terms of three years. Members may serve an unlimited
number of terms. When a vacancy occurs as a result of the
expiration of a term or otherwise, a successor of like
qualifications shall be appointed.
(c) The advisory committee shall meet at least annually to
review the status of uniform credentialing in this state, and may
make further recommendations to the Secretary of the Department of
Health and Human Resources and the Insurance Commissioner as are
necessary to carry out the purposes of this article. Any uniform forms and the list of health care practitioners required to use the
uniform forms as set forth in legislative rule proposed pursuant to
section two of this article may be amended as needed by procedural
rule.
(d) The Secretary of the Department of Health and Human
Resources and the Insurance Commissioner shall collaborate with the
CVO and the advisory committee established above, to update the
uniform credentialing form for use by all health care
practitioners. In addition, the Council for Affordable Quality
Healthcare and the state uniform credentialing form shall be
acceptable.
§16-1A-6. Report required.
On or before January 1, 2010, the department and the
commission shall jointly report to the Legislative Oversight
Commission on Health and Human Resources Accountability on the
need, if any, for further legislation to implement the use of the
uniform credentialing application form developed pursuant to the
legislative rule authorized by section two of this article and the
CVO legislation authorized in 2009.