Relates to the definition of a clinical peer reviewer

1 Co-sponsor

• Ruben Diaz

Title of bill

An act to amend the public health law and the insurance law, in relation to the definition of clinical peer reviewer

Purpose or general idea of bill

To ensure that a health plan may only contradict the treatment recommendation of a patient's treating physician upon the review of a licensed physician in the same or similar specialty as the physician recommending the treatment.

Summary of specific provisions

Would amend section 4900 of the Public Health Law and section 4900 of the Insurance Law to re-define the qualifications of a "clinical peer reviewer". A "clinical peer reviewer" is the only type of health care provider who a health plan or insurer may use to render an adverse determination to the treatment recommendation of a patient's physician. Under current law, the only qualification for such a "clinical peer reviewer" is that he or she be a licensed physician.

This legislation would require that such physician be board-certified or board eligible in the same or similar specialty as the physician who typically recommends the treatment or manages the condition under review.

Justification

Under current law, the only qualification required for a person who, on behalf of a health care plan or insurer, may contradict the treatment recommendation of the patient's treating physician is that such reviewer be a licensed physician. There is no requirement that the reviewing physician be trained in the same specialty as the physician who would typically recommend the treatment that is under review. Therefore, a patient's treatment recommendation may be reviewed by a provider working for the health plan who is not qualified to review the treatment that has been recommended. This can result in medically necessary care being inappropriately denied or unnecessarily delayed while the patient has to resort to taking an External Appeal to attempt to receive their needed care.

The similar specialty qualification had been a requirement for a health care plan's reviewing physician from 1997 to 1999, as it had been required by the 1996 Managed Care Bill of Rights. However, in 1998, in enacting the External Appeals Law, the requirement that the health care provider reviewing the treatment recommendations of a treating physician be a physician trained in the same or similar specialty was not continued. This legislation would restore this requirement, and ensure that such reviewing physicians be either board certified or board eligible in that specialty.

Prior legislative history

2002: A.11479 - passed Assembly 2004: A.3441 - passed Assembly 2005-06: A.2206-B - passed Assembly 2007-08: A.4609 - passed Assembly

Fiscal implications

None

Effective date

Ninety days after enactment.