February 22, 2001

For more information contact:

Stanley S. Jones, Jr.

404-817-6133

           Today was a busy day under the Dome.  Legislators were anxious to get things accomplished so they could take advantage of the long weekend as the General Assembly has recessed until Monday in an effort to allow the Conference Committee to work on the FY 2001 Budget over the weekend.  today was "disabilities day" at the Capitol – advocates were working on various issues, including “Unlocking the Waiting Lists,” an effort to better meet the community's needs with community-based services. 

Floor Activity 

          There were a number of bills on both the House and Senate calendars.  Some of the more noteworthy were: 

HB 195 – The Senate voted on its motion to reconsider its action on the optometrists bill which would expand the optometrists’ scope of practice.  The vote cleared the Senate by 26 to 24 votes, thus allowing the optometrists to once again have a chance.  Now, the bill goes back to the Senate Rules Committee where it will once again be requested to be placed on the Senate’s calendar.  In an interesting maneuver by the physicians opposed to this legislation, the Medical Association of Georgia had the halls filled with physicians in white coats early this morning.  

HB 174 – The Senate voted out its version of the State’s Budget for the Supplemental FY 2001 Budget.  Each of the various Subcommittees made their reports on inclusions in this year’s Supplemental Budget.  As usual, there were a number of Republicans who raised questions and proposed a few amendments.  After a hearing on the items presented, the Bill passed. 

Newly Introduced Legislation 

HB 652 – Rep. Dodson and others have introduced this bill, which has already been heard by the Industry Committee, amending Chapter 1 of Title 43 concerning the surveys of licensees and the reporting of that data to the Department of Community Health.  This is primarily targeted to tracking the licenses issued to nurses around the State. 

HB 657 – Rep. Broome and others have introduced an amendment to Georgia’s RICO Statute found at O.C.G.A. § 16-14-3 in an effort to change the definition of “pattern of racketeering activity” so that it will mean: “Committee Activity engaging in at least two acts of racketeering activity in furtherance of one or more incidents, schemes, or transactions that have the same or similar intents, results, accomplices, victims, or methods of commission or otherwise are interrelated by distinguishing characteristics and are not isolated incidents, provided at least one of such acts occurred after July 1, 1980, and that the last of such acts occurred within four years, excluding any periods of imprisonment, after the commission of a prior act of racketeering activity.”  The proposal, if passed, would take effect on July 1, 2001 and would apply where at least one act of racketeering activity occurs on or after that date.  The prior law would continue to apply with respect to a pattern of racketeering activity which does not include at least one act of racketeering activity occurring on or after that date. 

HB 662 – Reps. Borders, Royal, Buck, Skipper and Black have authored this bill amending expenditures of revenue under the Georgia Fiscal Note Act found at O.C.G.A. § 28-5-42 in an effort to make sure that fiscal notes requested by General Assembly members are delivered in a timely manner and if not then the bill shall be deemed to have no significant impact upon anticipated revenues or expenditures.  

HB 711 – This bill amends Article 1 of Chapter 18 of Title 45 of the Code relating to state employees’ health insurance plans in an effort to provide for senior citizens to obtain cards enabling them to obtain prescription drugs at reduced prices.  This would add a new Code section at O.C.G.A. § 45-18-6.1 and would impact those persons ages 62 and older.  The citizens would obtain Georgia Care Cards for an annual fee not to exceed $10.00.  Such cards would be used in obtaining prescription drugs.  Any pharmacy, pharmacist, insurer or other entity who contracts with the Board or the health insurance plan established under this Article would be impacted. 

HB 716 – Reps. Harbin, Graves, Watson, and Parrish have authored this amendment to the Insurance Code concerning the enactment of the “Fair Insurance Business Practices Act of 2001.”  The bill relates to the bargaining between physicians and health insurance plans over contracts.  The bill would impact “carriers” of accident and sickness insurers, fraternal benefit societies, hospital service corporations, medical service corporations, health care corporations, health maintenance organizations, provider sponsored health care corporations, or other similar entities and any self-insured health benefit plans not subject to the ERISA Act of 1974 found at 29 U.S.C. Section 1001, et seq. Some of the bill’s provisions include: 

“33-20A-63.
(a) Every physician contract entered into, amended, extended, or renewed after July 1, 2001, by a carrier shall contain a specific provision which shall provide that any physician who is terminated from the physician contract while treating an enrollee or enrollees of such carrier for pregnancy or for a degenerative, disabling, or terminal condition shall continue to be allowed to treat such patient under the terms of the physician contract and shall continue to be compensated under the terms of the physician contract for a period of at least 90 days following such termination.
(b) In the event that a patient's insurance carrier or health benefit plan terminates that patient's physician from the patient's health care benefit plan while the patient is being treated for pregnancy or for a degenerative, debilitating, or terminal condition, the patient shall within a period of 30 days following such termination have the option to change his or her health insurance coverage to include the consumer choice option described in Code Section 33-20A-9.1 without the necessity of waiting for an open enrollment period or other such limitation on changes in insurance coverage during the plan year.

33-20A-64.
No carrier or its network, physician panel, or intermediary may terminate or fail to renew any physician contract or the employment or other contractual relationship with a physician or otherwise penalize any physician without first providing to the physician a detailed explanation in writing of each and every cause for such action.

33-20A-65.
No carrier may require as a condition precedent of a physician contract that a physician participate in all or substantially all of the physician panels operated by the carrier or by any other entity in order for the physician to participate in any of such carrier's physician panels.  Every physician contract entered into, amended, extended, or renewed on or after July 1, 2001, by a carrier shall contain a specific provision which shall provide that a physician shall be free to accept or decline participation in a physician panel and that such choice by a physician shall not be a ground for denying participation in any other physician panel.

33-20A-66.
Every physician contract entered into, amended, extended, or renewed on or after July 1, 2001, by a carrier shall contain specific provisions which shall require the carrier to adhere to and comply with the following minimum fair insurance business standards in the processing and payment of claims for health care services:
(1) Every carrier shall establish and implement reasonable policies to permit any physician with whom there is a physician contract:
(A) To confirm in advance during normal business hours by either free telephone or electronic means whether the health care services to be provided are a covered benefit; and
(B) To determine the carrier's requirements applicable to the physician or to the type of health care services which the physician has contracted to deliver under the physician contract for:
(i) Precertification or authorization of coverage decisions;
(ii) Retroactive reconsideration of a certification or authorization of a coverage decision or retroactive denial of a previously paid claim;
(iii) Physician-specific payment and reimbursement methodology, coding levels and methodology, downcoding, and bundling of claims; and
(iv) Other applicable physician-specific claims processing and payment matters necessary to meet the terms and conditions of the physician contract;
(2) Every physician contract must include or attach at the time it is presented to the physician for execution all material addenda and exhibits thereto and any policies, including those referred to in paragraph (1) of this Code section, applicable to the physician or to the range of health care services reasonably expected to be delivered by the physician under the physician contract;
(3) No amendment to any physician contract or to any addenda, schedule, exhibit, or policy thereto or new addenda, schedule, exhibit, or policy applicable to the physician or to the range of health care services reasonably expected to be delivered by the physician shall be effective as to the physician unless the physician has been provided with the applicable portion of the proposed amendment or of the proposed new addenda, schedule, exhibit, or policy and the physician has failed to notify the carrier within 30 days of receipt of the documentation of the physician's intention to terminate the physician contract at the earliest date thereafter permitted under the physician contract; and
(4) No carrier may impose on a physician any retroactive denial of a previously paid claim or any part thereof unless:
(A) The carrier has provided to the physician in writing the reason for the retroactive denial;
(B) The time which has elapsed since the date of the payment of the original challenged claim does not exceed the lesser of 12 months or the number of days within which the carrier requires under its physician contract that a claim be submitted by the physician following the date on which a health care service is provided; and
(C) Either:
(i) The original claim was submitted fraudulently;
(ii) The original claim payment was incorrect because the physician was already paid for the health care services identified in the claim; or
(iii) The health care services identified in the claim were not delivered by the physician.
Effective July 1, 2001, a carrier shall notify a physician at least 30 days in advance of the imposition of any retroactive denial of a claim.

33-20A-67.
Every carrier subject to regulation by this title shall adhere to and comply with the minimum fair business standards required under Code Section 33-20A-66 and the Commissioner shall have jurisdiction to determine if a carrier has violated the standards set forth in Code Section 33-20A-66 by failing to include the requisite provisions in its physician contracts and shall have jurisdiction to determine if the carrier has failed to implement the minimum fair business standards set forth in Code Section 33-20A-66.

33-20A-68.
No carrier or its network, physician panel, or intermediary may terminate or fail to renew any physician contract or the employment or other contractual relationship with a physician or otherwise penalize a physician for invoking any of the physician's rights under this article or under the physician contract.

33-20A-69.
No carrier shall be in violation of this article if the carrier's compliance is rendered impossible due to matters beyond the carrier's reasonable control including, but not limited to, an act of God, insurrection, strike, power outage, and fire, which are not caused in material part by the carrier.

33-20A-70.
Any physician who suffers loss as the result of a carrier's violation of this article or a carrier's breach of any physician contract provision required by this article shall be entitled to initiate an action to recover actual damages.  If the trier of fact finds that the violation or breach resulted from a carrier's gross negligence or willful conduct, it may increase damages to an amount not exceeding three times the actual damages sustained. Notwithstanding any other provision of law to the contrary, in addition to any damages awarded, such physician also may be awarded reasonable attorney's fees and court costs.  Each claim for payment that is paid, denied, or otherwise processed in violation of this article or with respect to which a violation of this article exists shall constitute a separate violation.  The Commissioner shall not be deemed to be a trier of fact for purposes of this Code section.”

HB 720 – Rep. Harbin, along with others, introduced this amendment to Chapter 24 of Title 33 concerning health insurance in an effort to require health care insurers to provide their insureds with an explanation of benefits statements.  The bill also defines these new explanation of benefits statements.  As used in this Code Section, “explanation of benefits” means “a written notification provided by the health insurer or health claim payor upon payment by the insurer or payor to the health care provider for its service or services, which explains how the benefits of the insured's health benefit plan apply to the charges for the particular service or services rendered on a specific occasion by a health care provider.”
This bill inserts a new Code Section at 33-24-43.1.

“(1) Full name of payor;
(2) Full name of physician network accessed for discount, if applicable;
(3) Telephone number for claims information and eligibility;
(4) Full name of insured;
(5) Full name of patient;
(6) Member identification number;
(7) Patient account number; and
(8) An explanation of all charges, discounts, and payments for the particular date of service itemized by the following:
(A) Date of service;
(B) CPT code;
(C) Charged amount;
(D) Allowed amount;
(E) Discount amount;
(F) Patient responsibility amount; and
(G) Amount paid by health insurer or health claim payor.”

          A separate explanation of benefits would have to be provided for each date of service.  Each of the health insurers and health claim payors would also be required to use the same terminology in preparing their explanation of benefits statements. 

HR 275 – This Resolution was introduced by Chairman Buddy Childers in an effort to urge that the Department of Community Health adopt certain reimbursement methodologies for nursing facilities.  This is so that more current cost reports may be used.  This too has already been heard by the House Health and Ecology Committee. 

HR 338 – Rep. Smith and others are proposing this Resolution which would urge the Department of Administrative Services to urge the Georgia Technology Authority to promote the distribution and access to public reports through a state electronic directory.  This is an effort to cut the state’s printing costs.  

SB 214 – Sens. Polak and Lamutt have introduced this bill amending Chapter 1 of Title 10 relating to the selling and other trade practices of data bases.  This is an effort to provide limited protections of owners of databases against unauthorized commercialization.  It would be known as the “Georgia Data Base Protection and Economic Development Act of 2001.” 

SB 213 – Sen. Hill has introduced these amendments to the Code.  Some of the bill’s provisions would amend O.C.G.A. § 15-7-21 relating to the qualifications of state court judges so as to change the provisions concerning non-partisan primaries and O.C.G.A. § 20-2-56 concerning the non-partisan primaries and elections for members of the boards of education.

Committee Activity 

House Insurance Committee 

          The House Insurance Committee met today with a Subcommittee being first called by Rep. Keith Heard to hear HR 352, a resolution brought to the Subcommittee’s attention by the Georgia Association of Health Underwriters (“GAHU”).  GAHU explained that its interest in this Resolution is to help address the problems that the State has encountered by the growing number of uninsured persons.  This would create the Blue Ribbon Commission on Individual Health Insurance Availability and its Effect on the Employer Based Health Insurance Market. There will be fifteen members on this Commission and it will be composed of the following: three members of the Senate appointed by the President of the Senate, three additional members appointed by the President of the Senate, three members of the House of Representatives appointed by the Speaker of the House of Representatives, three additional members appointed by the Speaker of the House of Representatives, the Commissioner of Insurance or his or her designee, the commissioner of the Department of Community Health or his or her designee, and the consumer insurance advocate or his or her designee.  This passed out of the Subcommittee with a couple of changes – one of which would require that this Commission prepare a written report.  After passing the bill out of the Subcommittee as amended, the bill then proceeded to the full Committee where it passed out.  The Resolution now proceeds to House Rules. 

          Late this afternoon, the Budget Conferees began their deliberations over the FY 2001 Supplemental Budget.  These Conferees include Reps. Terry Coleman, Larry Walker, and Tom Buck and Sens. George Hooks, Charles Walker, and Terrell Starr.  The plan is to work on this Budget over the weekend.  Thus, many advocates will be pulling a weekend shift at the Capitol in an effort to help keep their various monies in the Budget.  A full report on Budget details will come later. 

Other News 

          The Speaker’s bill on insurance liability, HB 478, is still under negotiation with the insurance industry and the trial lawyers.  It was initially expected that the bill would be heard in the House Judiciary Committee today but it was pulled again.  Also, HB 632 the bill proposed by the Medical Association of Georgia concerning the regulation of office-based surgeries by physicians and authored by Rep. Larry Walker, is now under some proposed ‘rewriting’ as HB 632 was engrossed.  It may now have a new bill dropped covering the same subject – but with the concerns about the hospitals addressed over the liability and credentialing involved.  HB 565, the bill authored by Chairman Jimmy Lord and Rep. Mark Burkhalter dealing with insurance coverage of the disease of autism, was to be heard in an Insurance Subcommittee this afternoon.  The meeting was cancelled and rescheduled for Monday, February 26, 2001 at 9:15 a.m.