(SB 1088) - This bill
requires an HMO that has a contract with a provider to disclose
to the provider, in an electronic or written format, the
complete schedule of reimbursement for which the HMO and the
health care provider have contracted, including any deviations
from the contracted schedule of reimbursement requested by the
HMO and agreed upon by the provider.
The bill also defines “schedule of reimbursement” as a “schedule
of fees to be paid by a health maintenance organization to a
physician provider for reimbursement for specific services
pursuant to the terms of a contract.” It does require that
disclosure of factors which may negatively impact net physician
reimbursement (such as bundling codes into another code) are
disclosed in the initial terms of the contract. The bill allows
for reimbursement schedules to be stated as a percentage of the
Medicare fee schedule for specific relative value services, a
listing of reimbursements to be paid by CPT codes or any other
method agreed to by the parties. Non-relative value services
shall be separate from relative value services, and
reimbursement for “unclassified services” shall be paid on a
“reasonable basis.”
The reimbursement schedule is subject to any non-disclosure
requirements of the contract and providers must maintain
confidentiality.
