Chapter 271 Oregon Laws 1999

Session Law

AN ACT

SB 562

Relating to independent practice associations; amending ORS 743.803 and section 7, chapter 759, Oregon Laws 1997; and declaring an emergency.

Be It Enacted by the People of the State of Oregon:

SECTION 1. ORS 743.803, as amended by section 4, chapter 759, Oregon Laws 1997, is amended to read:

743.803. (1) No medical services contract may require the provider, as an element of the contract or as a condition of compensation for services, to agree:

(a) In the event of alleged improper medical treatment of a patient, to indemnify the other party to the medical services contract for any damages, awards or liabilities including but not limited to judgments, settlements, attorney fees, court costs and any associated charges incurred for any reason other than the negligence or intentional act of the provider or the provider's employees;

(b) To charge the other party to the medical services contract a rate for services rendered pursuant to the medical services contract that is no greater than the lowest rate that the provider charges for the same service to any other person;

(c) To deny care to a patient because of a determination made pursuant to the medical services contract that the care is not covered or is experimental, or to deny referral of a patient to another provider for the provision of such care, if the patient is informed that the patient will be responsible for the payment of such noncovered, experimental or referral care and the patient nonetheless desires to obtain such care or referral; or

(d) Upon the provider's withdrawal from or termination or nonrenewal of the medical services contract, not to treat or solicit a patient even at that patient's request and expense.

(2) All medical services contracts shall:

(a) Grant to the provider adequate notice and hearing procedures, or such other procedures as are fair to the provider under the circumstances, prior to termination or nonrenewal of the medical services contract when such termination or nonrenewal is based upon issues relating to the quality of patient care rendered by the provider.

(b) Set forth generally the criteria used by the other party to the medical services contract for the termination or nonrenewal of the medical services contract.

(c) Entitle the provider to an annual accounting accurately summarizing the financial transactions between the parties to the medical services contract for that year.

(d) Allow the provider to withdraw from the care of a patient when, in the professional judgment of the provider, it is in the best interest of the patient to do so.

(e) Provide that a doctor of medicine or osteopathy licensed under ORS chapter 677 shall be retained by the other party to the medical services contract and shall be responsible for all final medical and mental health decisions relating to coverage or payment made pursuant to the medical services contract.

(f) Provide that a physician who is practicing in conformity with ORS 677.095 may advocate a decision, policy or practice without being subject to termination or penalty for the sole reason of such advocacy.

(g)(A) Entitle the party to the medical services contract who is being reimbursed for the provision of health care services on a basis that includes financial risk withholds, or the party's representative, to a full accounting of health benefits claims data and related financial information on no less than a quarterly basis by the party to a medical service contract who has made reimbursement, as follows:

(i) The data shall include all pertinent information relating to the health care services provided, including related provider and patient information, reimbursements made and amounts withheld under the financial risk withhold provisions of the medical services contract for the period of time under reconciliation and settlement between the parties.

(ii) Any reconciliation and settlement undertaken pursuant to a medical services contract shall be based directly and exclusively upon data provided to the party who is being reimbursed for the provision of health care services.

(iii) All data, including supplemental information or documentation, necessary to finalize the reconciliation and settlement provisions of a medical services contract relating to financial risk withholds shall be provided to the party who is being reimbursed for the provision of health care services no later than 30 days prior to finalizing the reconciliation and settlement.

(B) Nothing in this paragraph shall be construed to prevent parties to a medical services contract from mutually agreeing to alternative reconciliation and settlement policies and procedures.

(3) The other party to a medical services contract shall not:

(a) Refer to other documents or instruments in a contract unless the nonprovider party agrees to make available to the provider for review a copy of the documents or instruments within 72 hours of request; or

(b) Provide as an element of a contract with a third party relating to the provision of medical services to a patient of the provider that the provider's patient may not sue or otherwise recover from the nonprovider party, or must hold the nonprovider party harmless for, any and all expenses, damages, awards or liabilities that arise from the management decisions, utilization review provisions or other policies or determinations of the nonprovider party that have an impact on the provider's treatment decisions and actions with regard to the patient.

(4) An insurer, independent practice association, medical or mental health clinic or other party to a medical services contract shall provide the criteria for selection of parties to future medical services contracts upon the request of current or prospective parties.

[(5)(a) All medical services contracts between a provider and an independent practice association shall entitle a provider required to be credentialed by the association, or the provider's employer, to retroactive reimbursement by the association for covered treatment or services rendered by the provider before the provider was credentialed if, at the time the provider rendered the treatment or services:]

[(A) The provider had submitted a completed application to the association to be credentialed; and]

[(B) The provider had been granted clinical privileges by a hospital that is accredited by the Joint Commission on Accreditation of Healthcare Organizations.]

[(b) If 90 days have passed following the date a provider submitted a completed application to an independent practice association to be credentialed and the association has not yet completed its credentialing decision, the association shall report to the provider or the provider's employer regarding the status of the credentialing decision.]

[(c) A provider or the provider's employer seeking retroactive reimbursement pursuant to this subsection shall submit all bills for treatment or services rendered before the provider was credentialed to the independent practice association in a single group on or after the date the association credentials the provider. The independent practice association shall provide reimbursement to the provider or the provider's employer within 30 days of the date the association credentials the provider or within 30 days of the date the provider or the provider's employer submits the bills to the association pursuant to this paragraph, whichever date comes later.]

SECTION 2. Section 7, chapter 759, Oregon Laws 1997, is amended to read:

Sec. 7. [This Act is] Sections 1 to 3, chapter 759, Oregon Laws 1997, and the amendments to ORS 750.055 and 750.333 by sections 5 and 6, chapter 759, Oregon Laws 1997, are repealed on December 31, 1999.

SECTION 3. This Act being necessary for the immediate preservation of the public peace, health and safety, an emergency is declared to exist, and this Act takes effect on its passage.

Approved by the Governor June 16, 1999

Filed in the office of Secretary of State June 17, 1999

Effective date June 16, 1999

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