Relates to certain application and referral forms for health care plans

3 Co-sponsors

• John A. DeFrancisco
• Liz Krueger
• Michael H. Ranzenhofer

BILL NUMBER:S4511

Title of bill

An act to amend the public health law and the insurance law, in relation to certain application and referral forms for health care plans

Purpose or general idea of bill

To streamline and simplify the process by which physicians and other health care professionals are credentialed by health care plans and hospitals, as well as to standardize the referral forms that primary care physicians use to facilitate care for a patient by a specialist physician.

Summary of specific provisions

This bill amends section 4406-d, subdivision (I) of the public Health Law to create new paragraphs (c), (d), (e), (f), (a) and (h) that would establish a process for creating a standardized credentialing and renewal form for physicians and other health care professionals to use for the purpose of being accepted and retained on the panels of health care plans, as well as for the purpose of obtaining staff privileges at a hospital or other health care facility. Such credentialing form would be required to include provisions that would ensure that the form would be applicable for physician participation in the networks of government sponsored health plans, including Medicaid, Child Health Plus and Family Health Plus. It would also establish a similar process for creating a uniform referral form that physicians and other health care professionals may use in referring patients for specialty care. In addition, it would establish this universal referral form as the sole source of information required for credentialing, re-credentialing, and professional referrals.

Justification

Physicians currently need to spend an extensive amount of time completing paperwork in order to be credentialed by health care plans for participation in their networks, and by hospitals to be granted employment of staff privileges. Credentialing is the process by which physicians present documentation of their professional privileges, licensure, evidence of malpractice insurance and malpractice history to such health care plan or hospital for their review. While this is an important process for ensuring that a physician who will provide care for the enrollees of a health plan, or of the patients at a hospital, is properly qualified, the process can be unnecessarily cumbersome. Most insurers have different forms that essentially ask for the same information, creating additional unnecessary paperwork for the physician. This legislation would simplify this cumbersome process to facilitate the creation of a uniform credentialing and renewal form, and thereby reduce the administrative burden physicians currently have in completing these forms. This legislation calls for the forms to be devised with collaboration by all parties who regularly complete and review these forms, including health plans, hospitals, physicians and other health care providers.

Moreover, this legislation would also establish a similar process for creating a standard referral form that a primary care physician may use to facilitate making a referral when a patient needs to receive care from a specialist physician. As with credentialing forms, health care plans typically have their own referral authorization forms that arc substantially similar, but different such that the physician must use each plan's form. As with the uniform credentialing forms, a universal referral form would alleviate some of the administrative hassles that physicians face in attempting to facilitate necessary care for their patients.

Prior legislative history

2002: A.10483-A - Advanced to third reading 2003-04: A.5013 - Passed the Assembly 2005-06: A.5405 - Passed Assembly 2007-08: A.8163 - Passed Assembly 2009-10: A.764-A - Passed Assembly

Fiscal implications

None.

Effective date

This act shall take effect 180 days after it has become law.