RD696 - State Corporation Commission: Ethics and Fairness in Carrier Business Practices Work Group Report – December 1, 2023

Executive Summary:

Pursuant to Chapters 527 and 691 of the 2023 Virginia Acts of Assembly (Chapters 527/691), and on behalf of the State Corporation Commission (Commission), the Bureau of Insurance (Bureau) convened the Ethics & Fairness in Carrier Business Practices Work Group (E&F Work Group) to evaluate and develop recommendations for the implementation of fair business standards by health insurance carriers as set out in the Ethics & Fairness in Carrier Business Practices Act (§ 38.2-3407.15 of the Code of Virginia, hereinafter referred to as the E&F Act).

The E&F Work Group included representatives of the Virginia Hospital & Healthcare Association; the Virginia Association of Health Plans; and the Medical Society of Virginia. The Bureau encouraged the participation of other carrier and provider stakeholders, resulting in nearly 40 participants representing nine organizations routinely attending the virtual meetings. The Work Group agreed on seven consensus recommendations, including the following proposed changes to the E&F Act:

• Handle additional documentation requests and responses electronically to enhance the ability to match documents to claims and expedite processing. Specify that all contracts and contract amendments be delivered exclusively in electronic format and that the delivery method and location should be agreed to by both parties and memorialized via fully executed contract amendments;

• Require carriers to make available in the provider contract (to include the provider manual and relevant clinical guidelines) specific guidance regarding the documents and information required to be submitted by providers for payment of claims. The guidance should be easy to find, thorough, and easily accessible online.

• Establish a reasonable and consistent time limit for withholding or offsetting claims for known overpayments and duplicate claims;

• Require carriers to make available an electronic means for providers to determine if a member’s health plan is fully insured or self-funded beginning no later than July 1, 2025;

• Specify that carrier and provider subdelegates and vendors adhere to the requirements of the E&F Act, given that carriers and providers employ multiple vendors to perform tasks; and

• Clarify that carriers must apply payment timeliness requirements and related interest provisions to the resulting payments owed when the carrier overturns the denial of a claim following a review of a dispute; and

• Require parties to confer and compare their respective data at the claim level before submitting complaints to the Bureau to review.

Additionally, the Bureau presented the E&F Work Group with enhancements to its provider complaint form and improvements to its complaints review process. The Bureau will post the complaint investigation timeframes on its website.

The Bureau is willing to continue facilitating discussions as stakeholders work towards consensus on remaining issues.