Relates to the definition of a clinical peer reviewer

BILL NUMBER:S4783A REVISED 4/29/15

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 deny payment for an otherwise covered benefit upon the review of a physician or other health care professional licensed in NYS and, when appropriate, board certified in the same or similar specialty as treatment under review.

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 deny payment for an otherwise covered benefit on the basis that the treatment is not medically necessary. Under current law, only when a claim dispute arises to the level of an external appeal, does any qualification for such a "clinical peer reviewer" apply.

This legislation would

-require that when the clinical peer reviewer is a physician, he or she would 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;

-Require all clinical peer reviewers, whether physicians or other health care professionals, be licensed or certified in New York State;

-Apply the same qualifications for clinical peer reviewers to the initial internal health plan utilization review process

Justification

Under current law, the only qualification required for a utilization review agent, a person who, on behalf of a health rare plan or insurer, may deny payment for an otherwise covered benefit on the basis that it is not medically necessary, is that such reviewer be a physician or health care professional licensed somewhere and trained in utilization review practice. There is no requirement that the reviewing agent be trained in the same specialty as the health care professional 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

The similar specialty qualification had been required by the 1996 Managed Care Bill of Rights. However, in 1998, in enacting the External Appeals Law, the requirement was not continued for utilization review. This legislation would restore this requirement, and in addition, ensure that all reviewers at both levels of appeal be licensed or certified in New York state, and when appropriate, 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 2005-2006: A.2206-B - passed Assembly 2007-2008: A.4609 - passed Assembly 2009-2010: A.723 - passed Assembly 2011-2012: A.662 passed Assembly 2013-2014: A2693 - advanced to 3rd reading

Fiscal implications

None

Effective date

Ninety days after enactment.