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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