Welcome to the Ohio State Radiological Society

Back to November Issue Table of Contents

LEGISLATIVE UPDATE

The Patient Protection Act of 1999
Ohio Attorney General Opinion 99-044
Mandated Point of Service
Telemedicine

1. The Patient Protection Act of 1999 (AM. Sub. H.B.4)

General:
1. On July 13,1999, Governor Taft signed the Patient Protection Act of 1999 (the APPA).
2. Some provisions of the PPA become effective on October 14, 1999. One provision becomes effective on April 11, 2000. However, most provisions do not become effective until May 1,2000
Substantive Provisions:
The PPA builds on the managed care reforms from H.B. 361 (122nd General Assembly) in several ways.
1. Appeals:
  The PPA creates additional appeal rights.
  1. Internal Appeals:
    H.B. 361 enacted provisions regarding utilization review determinations and reconsideration of those determinations. If the utilization review determination or reconsideration is denied, the enrollee may initiate an internal appeal. The internal appeal procedures for health insuring corporations (HIS) were substantially reformed by the PPA.
    1. A decision on an internal appeal must be rendered within sixty (60) days, seven (7) days if the seriousness of the enrollee's condition requires an expedited review.
    2. If the service is denied because it is not medically necessary, the enrollee may seek an external review.
    3. If the HIC denies the service because it is not covered under the contract, the enrollee may ask the Superintendent of Insurance to review that issue.
      - If the Superintendent agrees that it is not covered, the HIC does not have to provide the service or an external review.
      - If the Superintendent states that the service requires the determination of a medical issue or is covered under the contract, the HIM must either cover the service or provide the enrollee with an external appeal.
  2. External Appeals:
    The PPA allows an enrollee to receive an opinion from an outside, independent entity which is knowledgeable about his or her condition.
    1. The external appeals process in H.B. 361 was only available to terminal patients who had been denied care based on the fact that the care was experimental, the PPA allows any enrollee to request an external review if the service is denied because it was determined not to be medically necessary and the service costs more than $500.
    2. The external review decision must be rendered by an Independent Review Organization (AIRO@) within thirty (30) days after the filing of the request for an external review, seven (7) days if the seriousness of the enrollee=s condition requires an expedited review.
  3. Applicability to Other Carriers:
    The PPA applies the appeal procedures not only to HICs, but also to indemnity health insurers and public employee benefit plans.
2. Emergency Services in Indenmity Plans:
  The PPA takes the emergency services mandate from H.B. 361 (which only applied to HICs) and applies it to indemnity insurers. Now, both carriers must cover emergency services for enrollees without regard to the day or time the emergency services are rendered or to whether the enrollee or the emergency department where the services are rendered obtained prior authorization for the emergency services.
3. OB/GUN Coverage:
  The PPA enacts a provision which allows female enrollees to obtain covered OB/GUN services from a participating OB/GUN without obtaining a referral from her primary care provider.
4. Independent Review Organizations (IROs):
  The PPA creates a formal process for the accreditation and selection of IROs.
5. Tax Provisions:
  The PPA allows taxpayers to deduct the amount paid for medical care insurance and long-term care insurance and allows taxpayers to deduct medical expenses from their adjusted gross income.

2. Ohio Attorney General Opinion 99-044

Utilization Review Determinations:
When rendered for the purposes of utilization review, an opinion regarding the medical necessity of physician services does not constitute the practice of medicine.
1. Rationale
  1. A HIM shall not be considered to be practicing medicine. Ohio Rev. Code 1751.08(D).
  2. Since a corporation can only act through it officers and agents, it follows that all persons employed by or acting on behalf of a HIM in making utilization review determinations shall also not be considered to be practicing medicine. The opinions of these persons are part of the process and thus, these decisions cannot be considered to be the practice of medicine.
2. Effect:
  These acts do not come within the regulatory, investigatory, or enforcement authority of the State Medical Board.
Appeals:
Opinions rendered during the appeals process of a HIM do not constitute the practice of medicine, even when the individual engaged in the determination process is an Ohio licensed physician.
1. Rationale
  1. A HIM shall not be considered to be practicing medicine. Ohio Rev. Code 1751.08(D).
  2. Since a corporation can only act through it officers and agents, it follows that all persons employed by or acting on behalf of a HIM in making utilization review determinations shall also not be considered to be practicing medicine. The opinions of these persons are part of the process and thus, these decisions cannot be considered to be the practice of medicine.
2. Effect:
  These acts do not come within the regulatory, investigatory, or enforcement authority of the Sate Medical Board.
Jurisdiction:
A physician's actions in offering a medical necessity opinion pursuant to a utilization review determination or an appeal may be subject to review by the State Medical Board if the Board receives a complaint alleging that the physician violated Ohio Revised Code 4731.22 (grounds for physician discipline).
1. Rationale
  1. Medical Standards:
    Some grounds for discipline in 4731.22 relate to minimal medical standards of care or treatment. As discussed above, a physician's opinion rendered during utilization review or an appeal is not the practice of medicine. Therefore, if the complaint alleges a violation of a provision that relates to minimum medical standards, the State Medical Board is without jurisdiction to review the alleged violation.
  2. Ethical Standards:
    Some grounds for discipline in 4731.22 relate to the ethical nature of physician's behavior. If the complaint alleges a violation of a provision that relates to ethical standards, the State Medical Board has jurisdiction to review the alleged violation.
2. Effect:
  The jurisdiction of the State Medical Board depends upon the nature of the complaint.

3. Mandated Point of Service

House Bill 16 (123rd General Assembly):
This legislation, sponsored by Rep. Mottley, created a task force to study consumer access to preferred provider plans, point of service plans, and other open panel plans for health care coverage. The legislation was signed by Governor Taft on June 15, 1999, and became effective that same day due to an emergency clause.
1. The Task Force will issue a report by December 31, 1999. This report will influence the outcome of any legislation on mandated point of service.
2. One bill has already been introduced which mandates that health plans offer a point of service plan. Sen. Blessing's S.B. 163 would require all closed panel plans offered by HICs to allow enrollees to use nonparticipating providers and to impose copayments on enrollees which reflect the HICS's actual costs in providing the out-of-panel access.

4. Telemedicine

Update:
1. Meetings with Rep. Rose Vesper and Rep. Dale Van Vyven.
2. Drafting of new legislation.
Proposed Amendments:
1. Informed Consent:
  Prior to the delivery of health care from a physician in another state, the patient must provide verbal and written consent. Consent becomes part of the medical record.
2. Jurisdiction of Ohio Courts:
  States that out-of-state physicians providing medical services to Ohio resident shall submit themselves to the jurisdiction of the courts of Ohio for any actions resulting from services performed.
3. Exemptions:
  States that the medical practice laws in Ohio do not apply to a physician in another state when the physician:
  1. Provides periodic consultation services to an Ohio practitioner without remuneration or the expectation thereof;
    1. Note:
      Episodic consultation used to be defined as consultation that occurs on an irregular basis and with respect to no more than 24 patients in any year and 12 follow-up visits with respect to each patient. That definition will be removed and will be left to the State Medical Board to define in rule.
  2. Provides academic consultation services to a medical school in this state;
  3. Provides medical services that are not available in this state;
  4. Provides decisions regarding the denial of coverage under health insurance policies.