Technical Assistance Advisory
To:All Health Carriers
From:Insurance Commissioner Deborah Senn
Subject:New rules governing provider relations
Date:Monday, October 18, 1999
Health plans sold to the public are only as valuable as the
health care network consumers must use. Continued
dissatisfaction in the health care community will result in
doctors and other health care professionals leaving these
networks. Recent turmoil in the health care community caused by
lopsided contracts that favor carriers should be reviewed as soon
as possible to reduce the frustration and anger among providers.
By July of next year, all new health care provider and facility
contracts must incorporate prompt payment standards.
Nevertheless, health carriers should make every effort to comply
with these new standards as soon as possible to resolve the long
simmering frustration with unnecessary delay in claim payments.
The extended time period for compliance was adopted in deference
to those carriers whose systems are incapable of rapid change.
Such circumstances are not true for all carriers.
In addition, carriers should immediately take steps to improve
communications with their providers. Many of the problems
addressed by the provider contracting rules arise out of poor
communication by carriers. Health carriers should clearly
describe the grounds and underlying reasons for rejection of
claims. Carriers should improve the notice given to providers of
changes in procedures along with explanations for these changes.
Carriers should make greater efforts to include network providers
in health care decisions and in the development of health care
utilization standards.
Finally, carriers should review their standards for dispute
resolution to ensure a process that providers will view as fair.
It is not enough to simply have a process. The purpose of
dispute resolution processes is to fairly respond to complaints
before the complaint becomes a major problem. Many contracts
that my office has reviewed can only lead to a conclusion that
carriers are interested in winning disputes rather than resolving
them. The new rules do not incorporate detailed standards for
dispute resolution in order to give carriers the opportunity to
develop better ones with the input from network providers.