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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | |||||||||||||||||||
5 | changing Section 368b as follows:
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6 | (215 ILCS 5/368b)
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7 | Sec. 368b. Contracting procedures.
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8 | (a) The General Assembly hereby finds and declares the | |||||||||||||||||||
9 | following:
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10 | (1) In an effort to reduce payments, some third party | |||||||||||||||||||
11 | payers are arbitrarily and inappropriately bundling | |||||||||||||||||||
12 | services such that participating physicians are being | |||||||||||||||||||
13 | denied payment for legitimate multiple services.
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14 | (2) This practice also has the effect of denying | |||||||||||||||||||
15 | payment for physician office visits and consultations | |||||||||||||||||||
16 | rendered on the same day that a medically necessary | |||||||||||||||||||
17 | therapeutic or diagnostic procedure is performed.
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18 | (3) The Centers for Medicare and Medicaid Services | |||||||||||||||||||
19 | recognized the impropriety of denying payment for office | |||||||||||||||||||
20 | visits and consultations rendered on the same day as a | |||||||||||||||||||
21 | medically necessary therapeutic or diagnostic procedure | |||||||||||||||||||
22 | and changed its Medicare reimbursement policy so that both | |||||||||||||||||||
23 | services are reimbursed when medically indicated.
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1 | (4) Third party payers often change their policies | ||||||
2 | relating to bundling without providing advance notice to | ||||||
3 | the physician of such changes.
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4 | (b) For the purpose of this Section, "third party payer" | ||||||
5 | means any insurer, health maintenance organization, | ||||||
6 | independent practice association, or physician hospital | ||||||
7 | organization.
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8 | (c) A third party payer shall adopt and implement policies | ||||||
9 | related to bundling of physician services submitted for | ||||||
10 | reimbursement that conform with the American Medical | ||||||
11 | Association's (AMA's) Current Procedural Terminology (CPT) | ||||||
12 | coding guidelines.
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13 | A third party payer must reimburse a physician for office | ||||||
14 | visits and consultations and therapeutic or diagnostic | ||||||
15 | procedures performed on the same day that the services are | ||||||
16 | medically indicated.
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17 | A third party payer shall not combine any individually | ||||||
18 | coded services submitted by the provider for reimbursement, | ||||||
19 | unless such action conforms to the AMA's Current Procedural | ||||||
20 | Terminology (CPT) coding guidelines, including, but not | ||||||
21 | limited to, the use of CPT modifiers, add-on codes, and | ||||||
22 | 51-exempt codes, and is in accordance with the third party | ||||||
23 | payer's policies regarding bundling, as agreed to in the | ||||||
24 | contract between the physician and third party payer.
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25 | A third party payer must provide written notice to the | ||||||
26 | physician of any change to its policy related to bundling at |
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1 | least 90 days prior to the effective date of the change.
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2 | (d)
(a) A health care professional or health care provider | ||||||
3 | offered a contract by
an
insurer, health maintenance | ||||||
4 | organization,
independent practice association, or physician
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5 | hospital organization for signature after the effective date of | ||||||
6 | this amendatory
Act of the
93rd General Assembly shall be | ||||||
7 | provided with a proposed health care
professional or
health | ||||||
8 | care provider
services contract including, if any, exhibits and | ||||||
9 | attachments that the contract
indicates are
to be attached. | ||||||
10 | Within 35 days after a written request, the health care
| ||||||
11 | professional or health
care provider offered a contract shall | ||||||
12 | be given the opportunity to review and
obtain a
copy of the | ||||||
13 | following: a specialty-specific fee schedule sample based on a
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14 | minimum of
the 50 highest volume fee schedule codes with the | ||||||
15 | rates applicable to the
health care
professional or health care | ||||||
16 | provider to whom the contract is offered, the
network
provider
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17 | administration manual, and a summary capitation schedule, if | ||||||
18 | payment is made on
a
capitation basis. If 50 codes do not exist | ||||||
19 | for a particular specialty, the
health care
professional or | ||||||
20 | health care provider offered a contract shall be given the
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21 | opportunity to
review or obtain a copy of a fee schedule sample | ||||||
22 | with the codes applicable to
that
particular specialty. This | ||||||
23 | information may be provided electronically. An
insurer, health
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24 | maintenance organization, independent practice
association, or | ||||||
25 | physician hospital
organization may substitute the fee | ||||||
26 | schedule sample with a document providing
reference
to the |
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1 | information needed to calculate the fee schedule that is | ||||||
2 | available to
the public at no
charge and the percentage or | ||||||
3 | conversion factor at which the insurer, health
maintenance
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4 | organization, preferred provider organization, independent | ||||||
5 | practice
association, or physician hospital organization sets | ||||||
6 | its rates.
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7 | (e)
(b) The fee schedule, the capitation schedule, and
the | ||||||
8 | network provider
administration manual constitute | ||||||
9 | confidential, proprietary, and trade secret
information and | ||||||
10 | are subject to the provisions of the Illinois Trade Secrets
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11 | Act.
The health
care professional or health care provider | ||||||
12 | receiving such protected information
may disclose
the | ||||||
13 | information on a need to know basis and only to individuals and | ||||||
14 | entities
that provide
services directly related to the health | ||||||
15 | care professional's or health care
provider's decision
to enter | ||||||
16 | into the contract or keep the contract in force. Any person or | ||||||
17 | entity
receiving or
reviewing such protected information | ||||||
18 | pursuant to this Section shall not
disclose
the
information to | ||||||
19 | any other person, organization, or entity, unless the | ||||||
20 | disclosure
is requested
pursuant to a valid court order or | ||||||
21 | required by a state or federal government
agency.
Individuals | ||||||
22 | or entities receiving such information from a health care
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23 | professional
or health care provider as delineated in this | ||||||
24 | subsection are subject to the
provisions of the
Illinois Trade | ||||||
25 | Secrets Act.
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26 | (f)
(c) The health care professional or health care |
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1 | provider shall be allowed at
least
30 days to review the health | ||||||
2 | care professional or health care provider services
contract, | ||||||
3 | including
exhibits and
attachments, if any, before signing. The | ||||||
4 | 30-day review period begins upon
receipt of the
health care
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5 | professional or health care provider services contract, unless | ||||||
6 | the information
available
upon request
in subsection (d)
(a) is | ||||||
7 | not included. If information is not included in the
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8 | professional
services contract and is requested pursuant to | ||||||
9 | subsection (d)
(a) , the 30-day
review period
begins on the date | ||||||
10 | of receipt of the information. Nothing in this subsection
shall | ||||||
11 | prohibit
a health care professional or health care provider | ||||||
12 | from signing a contract
prior to the
expiration of the 30-day | ||||||
13 | review period.
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14 | (g)
(d) The insurer, health maintenance organization,
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15 | independent practice
association, or physician hospital | ||||||
16 | organization shall provide all contracted
health care
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17 | professionals or health care providers with any changes to the | ||||||
18 | fee schedule
provided
under subsection (d)
(a) not later than | ||||||
19 | 35 days after the effective date of the
changes,
unless such
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20 | changes are specified in the contract and the health care | ||||||
21 | professional or
health care
provider is able to calculate the | ||||||
22 | changed rates based on information in the
contract and
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23 | information available to the public at no charge. For the | ||||||
24 | purposes of this
subsection,
"changes" means an increase or | ||||||
25 | decrease in the fee schedule referred to in
subsection (d)
(a) .
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26 | This information may be made available by mail, e-mail, |
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1 | newsletter, website
listing, or
other reasonable method. Upon | ||||||
2 | request, a health care professional or health
care provider
may | ||||||
3 | request an updated copy of the fee schedule referred to in | ||||||
4 | subsection (d)
(a)
every
calendar quarter.
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5 | (h)
(e) Upon termination of a contract with an insurer, | ||||||
6 | health maintenance
organization, independent practice
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7 | association, or physician hospital
organization and at
the | ||||||
8 | request of the patient, a health care professional or health | ||||||
9 | care provider
shall transfer
copies of the patient's medical | ||||||
10 | records. Any other provision of law
notwithstanding, the
costs | ||||||
11 | for copying and transferring copies of medical records shall be | ||||||
12 | assigned
per the
arrangements agreed upon, if any, in the | ||||||
13 | health care professional or health
care provider services
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14 | contract.
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15 | (Source: P.A. 93-261, eff. 1-1-04.)
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