SB 4 does not require written notification to providers or beneficiaries pertaining to supporting documentation, why a claim was denied, and other notifications. The AMC/NOMA believes that the notification to providers and their beneficiaries should be in writing so that there is written documentation on file.

SB 4 allows third party payers to enter into other contractual agreements that differ from the provisions allowed for in the bill. The AMC/NOMA is of the opinion that this provides the third party payers with a loophole to negotiate contract parameters outside of what is outlined in the bill. The current language is ambiguous and should be clarified or deleted.

SB 4 establishes the monetary penalties the Superintendent may impose on third party payers; however, this section does not apply to complaints by providers or beneficiaries. The AMC/NOMA believes that complaints of providers should be included under section 3901.3812.

In addition, SB 4 prohibits the Superintendent from using findings from third party payer reports as a basis of a finding of a violation or the imposition of penalties. The AMC/NOMA would like to see language added to the bill that would enable the Ohio Department of Insurance to utilize the reports submitted by the third party payers for compliance purposes.

SB 4 allows the Superintendent is to prescribe the claim form that is to be utilized as the standard claim form by third party payers. However, in section 3902.22 of the Ohio Revised Code there is language which allows the Superintendent to “prescribe a separate claim form for each third party payer.” AMC/NOMA has asked that this language should be removed in its entirety from the bill, so that it is clear that the superintendent will establish a standard claim form for usage by all third party payers.

The bill provides for the creation of a system in which providers and beneficiaries can check on the status of their claims. The AMC/NOMA believes that this system should be Internet based.

The bill as originally introduced allowed third party payers to pay the undisputed portions of a claim before the disputed portions of a claim were resolved. This provision has been removed from the bill as passed by the Senate. The AMC/NOMA is of the opinion that if there is an undisputed portion of a claim it should be paid immediately while the rest of the claim is processed.

The bill provides that a payment is considered final two years after it is made and any improper payment can only be recovered if initiated before that date. The AMC/NOMA believes that payment should be considered final after one year and would like to see that time frame reduced to one year. In addition, the language that allowed for a repayment schedule to be arranged between a provider and a third party payer has been removed from the bill. If the repayment schedule is not included in the final bill, the AMC/NOMA believes that there should be a cap on how much a third party payer can reclaim from a provider in a given time frame to avoid any cash flow problems for physicians.

The AMC/NOMA is working with the state association as well as a coalition of other providers on SB 4. We will continue to evaluate and suggest changes to the bill that are in the best interest of our members. For more information contact Elayne R. Biddlestone at 216-520-1000, ext. 321 or at ebiddlestone@en.com.