HEALTH LAW ALERT
Vol. II, No. 1
October, 1999
1999 LOUISIANA HEALTH CARE LEGISLATIVE UPDATE
The 1999 Regular Legislative Session resulted in several important new laws intended to increase the accountability of insurers and health maintenance organizations in their key role in the delivery of health care. Below are summaries of some of the more important enactments. New Provider Claims Payment Standards
House Bill No. 2052 imposes new standards on claims payment by insurers. The following standards were established for non-electronic claims:
(1) Claims submitted within 45 days from the date of service by contracted providers must be paid no later than 45 days from the date a correctly completed uniform claim form is received, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard. (2) Claims submitted more than 45 days from the date of service by contracted providers, or claims resubmitted to correct a deficiency, must be paid no later than 60 days from the date a correctly completed uniform claim form is received, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard. (3) Claims submitted by insureds or non-contracted providers must be paid within 30 days from the date a correctly completed uniform claim form is received, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard. For electronic claims, the chief requirement is that all claims submitted electronically must be paid no later than 25 days from the date on which a correctly completed uniform claim for is electronically transmitted to the payor, unless just and reasonable grounds exist such as would put a reasonable and prudent businessman on his guard. For both electronic and non-electronic claims, the following apply: (1) The payor must establish procedures for reviewing claims for completeness within a reasonable period of time. It must provide written notice of the reason a claim cannot processed within two (2) business days from the date the claim was reviewed for completeness. (2) Claim amounts paid between 1-25 days after the foregoing time frames must include any late payment adjustment of 1% of the unpaid balance due for each month or partial month that the claim is unpaid. Claim amounts paid more than 25 days after the foregoing time frames must include a late payment adjustment of 2% of the unpaid balance due for each month or partial month that the claim is unpaid. This statute is currently in effect; however, full enforcement will probably be delayed until the Department of Insurance publishes regulations. Mandated Mental Illness Benefits
House Bill No. 1300 requires insurers, PPOs and HMOs doing business in Louisiana to provide benefits to severe mental illness under the same terms that apply to other illnesses covered under a plan. "Severe mental illness" is defined as (1) schizophrenia or schizoaffective disorder, (2) bipolar disorder, (3) pervasive developmental disorder or autism, (4) panic disorder, (5) obsessive-compulsive disorder, (6) major depressive disorder, (7) anorexia/bulimia, (8) Asperger's disorder, (9) intermittent explosive disorder, (10) post-traumatic stress disorder, (11) psychosis NOS when diagnosed in a child under 17 years of age, (12) Rett's disorder, and (13) Tourette's disorder. The bill also provided that insurers may offer, as an option, benefits for the treatment of other mental disorders under the same terms that apply to other covered illnesses. In order to be in compliance, a minimum of forty-five inpatient days and fifty-two outpatient visits must be covered. No waiting period in excess of sixty days may be imposed before benefits are available. The effective date is January 1, 2000.
New Standards for Medical Necessity Review
House Bill No. 2083 establishes comprehensive minimum standards for any entity that determines what medical services will be covered under a health plan based on medical necessity. This is a comprehensive statute that sets forth licensure requirements for medical necessity review organizations, sets maximum time frames for making medical necessity determinations, includes requirements for notifying the necessary parties of adverse determinations, requires detailed internal review procedures with clinical peer review, and mandates use of external review organizations.
Mandated Coverage for Certain Clinical Cancer Trials
Senate Bill No. 761 mandates coverage for costs of cancer treatments in Phase II, III or IV clinical trials, and protocol related care, if certain specific conditions are met. Among other requirements, the protocol must be approved by certain recognized entities, such as the Food and Drug Administration, the National Institutes of Health, or the Coalition of National Cancer Cooperative Groups.
This Health Law Alert is intended to provide information of general interest. Information is presented in summary form and should not be applied to a specific situation. If you have any questions or would like additional information regarding any of the above issues, please contact one of the following Gachassin Law Firm attorneys at (318) 235-4576 or by e-mail: Nicholas Gachassin, Jr.
E-mail: nick@gachassin.com
Richard A. MacMillan
E-mail: richard@gachassin.com
Rose Young
E-mail: rose@gachassin.com
Nicholas Gachassin, III
E-mail: nickiii@gachassin.com |
