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Committee Substitute House Bill 2885 History

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COM SUB 2 LINES
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.
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