Physical Therapy Association of Washington 360 352-7290 ...
Physical Therapy Association of Washington
208 Rogers St NW, Olympia WA 98502-4952
360 352-7290 ¡€ telephone
800 554-5569
360 352-7298 ¡€ facsimile
A Chapter of the American Physical Therapy Association
July 17, 2015
Office of the Insurance Commissioner
Jim Freeburg
PO Box 40258
Olympia, WA 98504
rulescoordinator@oic.
RE: Comments on CR-102 Insurance Commissioner Matter No. R 2014-08
Dear Mr. Freeburg,
On behalf of the Physical Therapy Association of Washington (PTWA), representing over
2500 physical therapists, physical therapist assistants and student members of the state
chapter of the American Physical Therapy Association, I¡¯d like to offer comments regarding
CR-102 Insurance Commissioner Matter No. R 2014-08: rules to ensure adequacy of access
in health insurers¡¯ provider networks.
First, PTWA commends the Commissioner on the content of this updated version. We
particularly support:
WAC 284-43-202 Maintenance of sufficient provider networks
(3) An issuer of a health plan must maintain and monitor, on an ongoing basis, the ability
and clinical capacity of its network providers and facilities to furnish covered health plan
services to enrollees. An issuer must notify the commissioner in writing within fifteen days
of a change in its network as described below:
(b) Termination or reduction of a specific type of specialty provider on the American Board
of Medical Specialties list of specialty and subspecialty certificates, where there are fewer
than two of the specialists in a service area;
WAC 284-43-225 Issuer recordkeeping¡ªProvider network
(2) Beginning January 1, 2016, an issuer must be able to provide to the commissioner upon
request the following information for a time period specified by the commissioner:
(a) The number of requests submitted for prior authorization for services by all providers and
facilities;
(b) The total number of such requests processed; and
(c) The total number of such requests denied.
WAC 284-43-300 Provider and facility contracts with ((health carriers)) issuers-Generally
(2) An issuer must ensure that subcontractors of its contracted providers and facilities
comply with the requirements of this subchapter. Provider networks must include and
maintain every provider category and type necessary to deliver covered services. An issuer's
obligation to comply with these requirements is nondelegable; the issuer is not exempt from
these requirements because it relied upon a third-party vendor or subcontracting
arrangement.
WAC 284-43-310 Selection of participating providers¡ªCredentialing and unfair
discrimination.
1. (c) Discriminate regarding participation in the network solely based on the provider or
facility type or category if the provider is acting within the scope of their license.
PTWA Comments
R 2014-08
Page 2
WAC 284-43-330 Participating provider¡ªFiling and approval.
6. If an issuer enters into a reimbursement agreement that is tied to health outcomes,
utilization of specific services, patient volume within a specific period of time, or other
performance standards, the issuer must file the reimbursement agreement with the
commissioner thirty days prior to the effective date of the agreement, and identify the
number of enrollees in the service area in which the reimbursement agreement applies.
Such reimbursement agreements must not cause or be determined by the commissioner to
result in discrimination against or rationing of medically necessary services for enrollees
with a specific covered condition or disease. If the commissioner fails to notify the issuer
that the agreement is disapproved within thirty days of receipt, the agreement is deemed
approved. The commissioner may subsequently withdraw such approval for cause.
Secondly, in order to ensure fair contracting practices between the carrier and the provider,
PTWA offers the following edits (highlighted in red):
WAC 284-43-320 Provider contracts¡ªStandards¡ªHold harmless provisions.
(2) Nothing contained in a participating provider or a participating facility contract
or Utilization Management (UM) Service Agreement or rules thereof, may have the effect of
modifying benefits, terms, or conditions contained in the health plan. In the event of any
conflict between the contract or UM rules and a health plan, the benefits, terms, and
conditions of the health plan ((shall)) must govern with respect to coverage provided to
((covered persons)) enrollees.
(((2))) (3) Each participating provider and participating facility contract ((shall)) must
contain the following provisions ((or variations approved by the commissioner)):
(a) "{Name of provider or facility} hereby agrees that in no event, including, but not
limited to nonpayment by {name of ((carrier)) issuer}, {name of ((carrier's)) issuer's}
insolvency, or breach of this contract ((shall)) will {name of provider or facility} bill, charge,
collect a deposit from, seek compensation, remuneration, or reimbursement from, or have
any recourse against ((a covered person)) an enrollee or person acting on their behalf, other
than {name of ((carrier)) issuer}, for services provided pursuant to this contract. This
provision ((shall)) does not prohibit collection of {deductibles, copayments, coinsurance,
and/or payment for noncovered services}, which have not otherwise been paid by a primary
or secondary ((carrier)) issuer in accordance with regulatory standards for coordination of
benefits, from ((covered persons)) enrollees in accordance with the terms of the ((covered
person's)) enrollee's health plan nor does it prevent an enrollee from choosing not to use
their insurance benefits so long as the enrollee has agreed in writing prior to service.¡±
(6) (a) Participating providers and facilities must be given reasonable notice of not
less than sixty days of changes that affect provider or facility compensation ((and)) or that
affect health care service delivery unless changes to federal or state law or regulations make
such advance notice impossible, in which case notice ((shall)) must be provided as soon as
possible. All contract changes affecting direct or indirect compensation must be
acknowledged by affirmative agreement and cannot take effect until such affirmative action
is obtained. Should affirmative action not be obtained, insurer shall follow due process for
contract termination including notification process.
(8) Subject to applicable state and federal laws related to the confidentiality of
medical or health records, an issuer must require participating providers and facilities to
make health records available to appropriate state and federal authorities involved in
assessing the quality of care or investigating ((the grievances or complaints of covered
persons subject to applicable state and federal laws related to the confidentiality of medical
or health records)) complaints, grievances, appeals, or review of any adverse benefit
determinations of enrollees. An issuer must require providers and facilities to cooperate with
audit reviews of encounter data in relation to the administration of health plan risk
PTWA Comments
R 2014-08
Page 3
adjustment and reinsurance programs. Audit reviews may not be performed to discriminate
against enrollees or to retaliate against providers.
(9) An issuer and participating provider and facility ((shall)) must provide at least
sixty one-hundred and twenty days' written notice to each other before terminating the
contract without cause.
WAC 284-43-330 Participating provider¡ªFiling and approval.
(1) ((A health carrier must file with the commissioner thirty calendar days prior to
use sample contract forms proposed for use with its participating providers and facilities. (2)
A health carrier shall submit material changes to a sample contract form to the
commissioner thirty calendar days prior to use. Carriers shall indicate in the filing whether
any change affects a provision required by this chapter.)) An issuer must file for prior
approval all participating provider agreements and facility agreements thirty calendar days
prior to use. If a carrier negotiates a provider or facility contract or a compensation
agreement that deviates from an approved agreement, then the issuer must file that
negotiated contract or agreement with the commissioner for approval thirty days before use.
The commissioner must receive the filings electronically in accordance with chapters 28444A, 284-46A, and 284-58 WAC. This filing process shall not prevent the insurer and
provider from negotiating a contract and its terms in good faith.
(2) (b) All negotiated contracts and compensation agreements must be filed with the
commissioner for approval thirty calendar days prior to use or take effect thirty calendar
days after filing with the commissioner and include all contract documents between the
parties. If the only negotiated change is to the compensation amount or terms related to
compensation, it must be filed and is deemed approved upon filing.
We thank you for your considerable work on the rulemaking process and are grateful for the
opportunity to comment.
Yours truly,
Elaine Armantrout, PT, DSc, ECS
President
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