An Act To Clarify Transparency of Medical Provider Profiling Programs Used by Insurance Companies and Other Providers of Health Insurance
Sec. 1. 24-A MRSA §2694-A, sub-§1, as enacted by PL 2009, c. 350, Pt. B, §1, is amended to read:
Sec. 2. 24-A MRSA §4301-A, sub-§16-A, as enacted by PL 2009, c. 439, Pt. B, §1, is amended to read:
Sec. 3. 24-A MRSA §4303, sub-§2, ¶E, as enacted by PL 2009, c. 439, Pt. B, §5, is amended to read:
(1) Disclose to providers the methodologies, criteria, data and analysis used to evaluate provider quality, performance , cost, including but not limited to unit cost, price and cost-efficiency ratings and, upon request from a provider evaluated on these bases, provide to that provider electronic copies of the data associated with the requesting provider and all adjustments to that data;
(2) Create and share with providers their provider profile at least 60 days prior to using or publicly disclosing the results of the provider profiling program;
(3) Afford providers the opportunity to correct errors, submit additional information for consideration and seek review of data and performance ratings; and
(4) Afford providers due process appeal rights to challenge the profiling determination described in this subsection and by Bureau of Insurance Rule Chapter 850, Health Plan Accountability.
If a carrier has a provider profiling program that includes out-of-network providers, a carrier must meet the requirements of this paragraph with regard to an out-of-network provider as well as for a provider in a carrier's network.
summary
This bill requires that any cost metric used by insurance providers in a provider profiling program is covered by the existing transparency provisions in the health plan improvement laws. The bill also requires carriers to provide copies of the data methodology used in the metric to affected providers. The purpose of this bill is to require all insurance providers, including the state health plan and other government insurance programs, to be included in this transparency obligation.