Disclosure of payment or fee schedule to managed care plan health care provider; Disclosure of schedule change; Confidentiality of payment information
See bold sections below:
(1) (a) An insurer issuing a managed care plan shall, upon request of a health care provider, provide or make available to the health care provider, when contracting or renewing an existing contract with such provider, the payment or fee schedules or other information sufficient to enable the health care provider to determine the manner and amount of payments under the contract for the health care provider’s services prior to final execution or renewal of the contract. The payment or fee schedule or other information submitted to a health care provider pursuant to this section shall include a description of processes and factors that may be applicable and that may affect actual payment, including copayments, coinsurance, deductibles, risk sharing arrangements, and liability of third parties. Nothing in this paragraph shall prohibit a plan from making any part of the information requested available electronically or via a Web site.
(b) An insurer issuing a managed care plan, upon request of a health care provider, shall provide or make available to the health care provider an explanation of the methodology, such as relative value unit system and conversion factor, percentage of Medicare payment system, or percentage of billed charges, used to determine actual payment for procedures frequently performed by the provider that involve combinations of services or payment codes, if the actual payment for the procedures cannot be ascertained from the fee schedule or other information submitted to a health care provider pursuant to this section. As applicable, the methodology disclosure provided for in this paragraph shall include:
1. The name of any relative value system;
2. The version, edition, or publication date of the relative value system; and
3. Any applicable conversion or geographic factor.
Nothing in this paragraph shall prohibit a plan from making any part of the information requested available electronically or via a Web site.
(c) The provisions of this subsection requiring the submission of a fee schedule or other information upon renewal of an existing contract shall not be applicable to renewal of an existing contract when the payment or fee schedule previously provided to the health care provider has not changed.
Fee schedules; Amendments
(2) Any change to payment or fee schedules applicable to providers under contract with an insurer issuing a managed care plan shall be made available to such providers at least ninety (90) days prior to the effective date of the amendment. This subsection shall not apply to changes in standard codes and guidelines developed by the American Medical Association or a similar organization.
(3) A health care provider receiving information pursuant to subsection (1) of this section shall not share this information with an unrelated person without the prior written consent of the insurer issuing a managed care plan. The remedies available to an insurer issuing a managed care plan to enforce the provision of this subsection shall include without limitation injunctive relief. An insurer issuing a managed care plan seeking extraordinary relief to enforce this section shall not be required to establish irreparable harm with regard to the sharing of competitively sensitive information.