New York - Volume III, Number 2 - September, 1998

EXTERNAL REVIEW, PROVIDER CONTRACTS SUBJECT OF NEW LAW

Under a newly enacted law, patients can request a state certified external review agent to determine whether their health insurer or managed care plan’s adverse coverage decision was reasonable, made with sound medical judgment, and in the best interest of the patient. A decision must be rendered within 30 days for routine cases and three days in emergency cases. Other provisions impose certain requirements for provider contracts, including an explanation of the payment methodology, time periods for claim payment, and the dispute resolution process to be used. Most of the law’s provisions become effective July 1, 1999.

DOH CHALLENGES "MOST FAVORED NATION" CLAUSE

The New York State Department of Health is investigating the use of a "most favored nation" clause in a new contract between Blue Cross & Blue Shield of Rochester and participating physicians in its affiliates’ managed care plan, Blue Choice HMO. The provision requires physicians to grant the insurer their best price for services. While not illegal, regulators fear competition is limited when "most favored nation" clauses are used by carriers that dominate a market.

EDUCATION DEPARTMENT GUIDANCE ON PHYSICIAN EXTENDERS

The New York State Education Department ("SED") has issued a memorandum clarifying practice rules for nurse practitioners ("NPs") and physician assistants ("PAs"). NPs must work within a specialty area in collaboration with a qualified physician, pursuant to a written practice agreement and approved practice protocols. NPs may write prescriptions, orders, and notes without co-signature, are eligible to apply for independent DEA numbers, and may prescribe schedule II-V controlled substances. NPs may have admitting privileges if granted by individual health facilities. PAs can perform services only under the continuous supervision of a physician; physician presence is not necessarily required. PAs can write prescriptions (on the physician’s form) and orders when assigned by the supervising physician, are eligible for their own DEA numbers, are permitted to function at a distance from the physician, and may provide services to a patient before the patient is seen by the physician.

HIV NOTIFICATION LAW ENACTED

Effective January 3, 1999, physicians must report to the New York State Health Commissioner the names of HIV-infected persons, similar to the current requirement to report persons with AIDS or AIDS-related illness. Names of contacts known to the physician or provided to the physician by the HIV-infected individual must also be reported. Local health officials then attempt to locate the contacts to provide information about HIV. While not obligated to do any contact tracing, the physician must report to the local health commissioner any efforts actually made to notify the contact. The physician would not be subject to criminal or civil liability if a good faith effort to report under the law has been made.