Before the Joint Committee on Health Care Financing
The Massachusetts Medical Society wishes to be recorded in strong support of the above referenced legislation legislation that would expand patient protections for MassHealth recipients and require MassHealth to adopt administrative reforms that would encourage physicians and other health care providers to participate in the program.
Specifically, H.1014 and S.552 would allow MassHealth recipients to appeal adverse determinations through the Office of Patient Protection (OPP). The OPP was created in 2000, through the enactment of Chapter 141 of the Acts of 2000 – the “Patients’ Bill of Rights, to protect Massachusetts managed care consumers and to grant healthcare consumers the right to challenge health plan coverage denials.” Chapter 224 of the Acts of 2012 transferred authority of the OPP from the Department of Public Health to the newly created Health Policy Commission (HPC).
Recently, the HPC Quality Improvement and Patient Protection Subcommittee held a Listening Session on the OPP internal and external review procedures. Data presented by HPC staff at that session showed the benefits of the OPP – of the 287 requests for external appeals filed by consumers in 2012, 35% were overturned, resulting in the carrier having to pay for treatment determined by the OPP to be medically necessary.
The MMS was very pleased to learn that the HPC intends to expand the OPP’s appeals process to include patients in Accountable Care Organizations (ACO’s) and Risk Bearing Provider Organizations. Howover, as was noted by the MMS and several other attendees at the session, the OPP is not available to MassHealth recipients, nor to state employees or consumers insured through self-insured plans, the latter of which is prohibited by federal ERISA statutes. H.1014 and S.552 would allow MassHealth recipients access to the benefits of the OPP. S.518, “An Act to Provide Access to Patient Protection Services for all Massachusetts Citizens”, also before this Committee, would extend the OPP to all citizens in Massachusetts. The MMS supports that bill as well.
Please note - S.518 includes the following language necessary for the Commonwealth to include MassHealth recipients in the OPP: “The Executive Office of Health and Human Services shall request Waivers from any federal laws or regulations which impede the effective implementation of this Act.” If H.1014 or S.518 advances out of Committee favorably, it should be amended to include this language.
H.1014 also includes several important provisions that would protect physicians who contract with MassHealth and encourage physicians to participate in the program. The bill would extend Timely Payment requirements, currently in place for private insurers, to MassHealth. The Division would have to pay for clean claims within 45 days of receipt and to notify providers within 15 days for written claims or 48 hours for electronic claims of any reasons for non-payment. H.1014 would also prohibit MassHealth from recouping, reducing, or retroactively denying payments to physicians for services provided over one year earlier. In cases where recouping, reducing, or retroactively denying payments to physicians is allowed, the Division would have to provide written notice at least 90 days prior to the implementation of such review.
Lastly, the MMS would like to be recorded in support H.1034, “An Act Relative to Administering National Standards to Medicaid Medical Necessity Reviews.” This bill would ensure that MassHealth utilizes an appropriate clinical peer reviewer, provides clear and timely notification to the recipient of appeals policy and procedures, and utilizes national evidence based medical standards and criteria for review determinations.
The MMS urges the Health Care Financing Committee to support all of the above referenced legislation to ensure that MassHealth recipients, and indeed, all public and privately insured citizens have access to the newly expanded Office of Patient Protection and that MassHealth adheres to the same fair contracting standards as are required for private insurers.
