95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
HB1075

 

Introduced 2/8/2007, by Rep. Kurt M. Granberg

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/368b

    Amends the Illinois Insurance Code. Requires a third party payer (i) to adopt and implement policies related to bundling of physician services submitted for reimbursement that conform with the American Medical Association's Current Procedural Terminology coding guidelines, (ii) to reimburse a physician for office visits and consultations and therapeutic or diagnostic procedures performed on the same day that the services are medically indicated, and (iii) to provide written notice to the physician of any change to its policy related to bundling at least 90 days prior to the effective date of the change. Makes related changes.


LRB095 04857 MJR 24919 b

 

 

A BILL FOR

 

HB1075 LRB095 04857 MJR 24919 b

1     AN ACT concerning regulation.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 368b as follows:
 
6     (215 ILCS 5/368b)
7     Sec. 368b. Contracting procedures.
8     (a) The General Assembly hereby finds and declares the
9 following:
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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
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
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
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

 

 

HB1075 - 4 - LRB095 04857 MJR 24919 b

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
4 organization, preferred provider organization, independent
5 practice association, or physician hospital organization sets
6 its rates.
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
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
23 professional or health care provider as delineated in this
24 subsection are subject to the provisions of the Illinois Trade
25 Secrets Act.
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
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
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.
14     (g) (d) The insurer, health maintenance organization,
15 independent practice association, or physician hospital
16 organization shall provide all contracted health care
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
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
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).
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.
5     (h) (e) Upon termination of a contract with an insurer,
6 health maintenance organization, independent practice
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
14 contract.
15 (Source: P.A. 93-261, eff. 1-1-04.)