SB246: Bill Text

SB246,7,5 (e) The independent review organization shall provide to the limited service health organization, preferred provider plan or managed care plan any additional information received from the enrollee under pars. (c) and (d). If, on the basis of the additional information, the limited service health organization, preferred provider plan or managed care plan reconsiders the enrollee's grievance and determines that the treatment that was the subject of the grievance should be covered, the independent review is terminated.

SB246,7,13 (f) If the independent review is not terminated under par. (e), the expert reviewers on behalf of the independent review organization shall, within 15 business days after the expiration of all time limits that apply in the matter, make a determination on the basis of the documents and information submitted under this subsection. The independent review organization shall send by 1st class mail to the commissioner, the enrollee and the limited service health organization, preferred provider plan or managed care plan a copy of the determination, which shall be in writing and state the basis for the decision.

SB246,7,18 (g) If, in the judgment of the enrollee's treating health care provider, the health condition of the enrollee is such that following the procedure outlined in pars. (a) to (f) would jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function, the procedure outlined in pars. (a) to (f) shall be followed with the following differences:

SB246,7,21 1. The limited service health organization, preferred provider plan or managed care plan shall submit the information under par. (a) within one day after receiving the notification under sub. (3) (b).

SB246,7,24 2. The independent review organization shall request any additional information under par. (d) within 2 business days after receiving the information under par. (a).

SB246,8,4 3. The enrollee or limited service health organization, preferred provider plan or managed care plan shall, within 2 days after receiving a request under par. (d), submit any information requested or an explanation of why the information is not being submitted.

SB246,8,7 4. The expert reviewers shall make their determination under par. (f) within 72 hours after the expiration of the time limits under this paragraph that apply in the matter.

SB246,8,10 (h) Any time limits specified in this subsection may be extended by mutual agreement between the enrollee, or his or her authorized representative, and the limited service health organization, preferred provider plan or managed care plan.

SB246,8,12 (i) Any information required or authorized to be submitted under this subsection may be submitted by facsimile or other electronic transmission.

SB246,8,14 (5) Standards for review. In making the determination under sub. (4) (f), all of the following apply:

SB246,8,19 (a) If coverage of the treatment that is the subject of the review was denied on the basis that the treatment was not medically necessary or appropriate, the expert reviewers shall find that the treatment was medically necessary and appropriate if, in light of conditions at the time the treatment was proposed, the treatment satisfied all of the following:

SB246,8,21 1. Was appropriate and consistent with the diagnosis and not providing it could adversely affect or fail to improve the enrollee's condition.

SB246,8,23 2. Was compatible with the standards of acceptable medical practice in the United States.

SB246,8,25 3. Was provided, or was to be provided, in a safe and appropriate setting, given the nature of the diagnosis and the severity of the symptoms.

SB246,9,2 4. Was not provided, or was not to be provided, solely for the convenience of the enrollee, the health care provider or the hospital.

SB246,9,4 5. Was not primarily custodial care, unless custodial care is a covered benefit under the enrollee's coverage.

SB246,9,7 (b) If coverage of the treatment that is the subject of the review was denied on the basis that the treatment was experimental, the expert reviewers shall find in favor of the enrollee if all of the following apply:

SB246,9,9 1. The treatment has been approved by the federal food and drug administration.

SB246,9,13 2. Medically and scientifically accepted evidence demonstrates that the expected benefits of the proposed treatment would be greater than the benefits of any available standard treatment and that the adverse risks of the proposed treatment are not substantially higher than those of standard treatments.

SB246,9,16 (c) The expert reviewers shall apply prudent professional practices and shall ensure that medically and scientifically accepted evidence supports the determination.

SB246,9,20 (6) Effect of determination. (a) A determination under sub. (4) (f) in favor of the enrollee is final and binding on the limited service health organization, preferred provider plan or managed care plan, which shall promptly comply with the determination.

SB246,9,25 (b) A determination under sub. (4) (f) in favor of the limited service health organization, preferred provider plan or managed care plan creates a rebuttable presumption in any subsequent action that the original coverage determination of the limited service health organization, preferred provider plan or managed care plan was appropriate.

SB246,10,6 (c) An independent review organization is immune from any civil or criminal liability that may result because of an independent review determination made under this section. An employe, agent or contractor of an independent review organization is immune from civil liability and criminal prosecution for any act or omission done in good faith within the scope of his or her powers and duties under this section.

SB246,10,9 (7) Independent review organizations; certification. (a) The commissioner shall certify and recertify independent review organizations that may conduct independent reviews under this section.

SB246,10,11 (b) An independent review organization shall submit to the commissioner in its application for certification the following information:

SB246,10,13 1. The names of all owners of more than 5% of any stock or options, if a publicly held organization.

SB246,10,14 2. The names of all holders of bonds or notes in excess of $100,000, if any.

SB246,10,17 3. The names and types of business of all corporations and organizations that the independent review organization controls or is affiliated with and the nature and extent of any ownership or control.

SB246,10,21 4. The names of all directors, officers and executives of the independent review organization and the nature of any relationship that a director, officer or executive has, if any, with a provider group or a health care insurer, including a limited service health organization, preferred provider plan or managed care plan.

SB246,10,23 (c) Within 30 days of any change in the information submitted under par. (b), the independent review organization shall notify the commissioner of the change.

SB246,11,3 (d) An independent review organization may not be a subsidiary of, or owned or controlled by, a health care plan, a trade association of health care plans or a professional association of health care providers.

SB246,11,5 (e) An expert reviewer assigned by an independent review organization to conduct a review must satisfy all of the following requirements:

SB246,11,8 1. Be a health care provider who is expert in treating the medical condition that is the subject of the review and who is knowledgeable about the treatment that is the subject of the review through actual clinical experience.

SB246,11,14 2. Hold a credential, as defined in s. 440.01 (2) (a), that is not limited or restricted; or hold a license, certificate, registration or permit that authorizes or qualifies the health care provider to perform acts that are substantially the same as those acts authorized by a credential, as defined in s. 440.01 (2) (a), that was issued by a governmental authority in a jurisdiction outside this state and that is not limited or restricted.

SB246,11,16 3. If a physician, hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the review.

SB246,11,19 4. Have no history of disciplinary sanctions, including loss of staff privileges, taken or pending by the medical examining board or another regulatory body or by any hospital or government.

SB246,11,22 (f) An independent review organization or an expert reviewer of the organization may not have any material professional, familial or financial conflict of interest with any of the following:

SB246,11,25 1. A limited service health organization, preferred provider plan or managed care plan that is involved in a review being conducted by the organization or reviewer.

SB246,12,3 2. An officer, director or management employe of a limited service health organization, preferred provider plan or managed care plan that is involved in a review being conducted by the organization or reviewer.

SB246,12,6 3. The health care provider, or the provider group or independent practice association of the health care provider, who proposed or who is proposing the treatment that is being reviewed.

SB246,12,8 4. The institution at which the treatment being reviewed was or would be provided.

SB246,12,9 5. The enrollee or his or her authorized representative.

SB246,12,10 6. The development or manufacture of the treatment being reviewed.

SB246,12,14 (g) An independent review organization shall have in operation a quality assurance mechanism to ensure the timeliness and quality of the reviews, the qualifications and independence of the expert reviewers and the confidentiality of the medical records and review materials.

SB246,12,17 (8) Rule making and reporting. (a) The commissioner shall promulgate rules for the implementation and operation of this section, including rules related to standards for certifying and recertifying independent review organizations.

SB246,12,19 (b) The commissioner shall provide a current listing of certified independent review organizations to all of the following:

SB246,12,21 1. Every limited service health organization, preferred provider plan and managed care plan that is subject to this section, at least quarterly.

SB246,12,22 2. Any person who requests a copy of the listing.

SB246,12,25 (c) The commissioner shall submit to the legislature under s. 13.172 (2) and to the governor an annual report on the operation of the independent review system under this section.

SB246, s. 6 Section 6 . Nonstatutory provisions.

SB246,13,11 (1) Rules regarding independent review. Using the procedure under section 227.24 of the statutes, the commissioner of insurance may promulgate rules required under section 609.16 (8) (a) of the statutes, as created by this act, for the period before the effective date of the permanent rules promulgated under section 609.16 (8) (a) of the statutes, as created by this act, but not to exceed the period authorized under section 227.24 (1) (c) and (2) of the statutes. Notwithstanding section 227.24 (1) (a), (2) (b) and (3) of the statutes, the commissioner is not required to provide evidence that promulgating a rule under this subsection as an emergency rule is necessary for the preservation of the public peace, health, safety or welfare and is not required to provide a finding of emergency for a rule promulgated under this subsection.

SB246, s. 7 Section 7. Effective dates. This act takes effect on the first day of the 13th month beginning after publication, except as follows:

SB246,13,15 (1) The treatment of section 609.16 (8) (a) of the statutes and Section 6 of this act take effect on the day after publication.

SB246,13,16 (End)