NOTICE OF PUBLIC HEARING
INSURANCE COMMISSIONER DONNA LEE H. WILLIAMS hereby gives notice that a PUBLIC HEARING will be held on Thursday, June 24th at 4:00 p.m. in Room A116, Delaware Technical & Community College, Stanton Campus, 400 Stanton-Christiana Road, Newark, DE.
The purpose of the Hearing is to solicit comments from the insurance industry and the general public on proposed Insurance Department Regulation 83, Standards of Payment for Assistants at Surgery.
The hearing will be conducted in accordance with the Delaware Administrative Procedures Act, 29 Del. C. Chapter 101. Comments are being solicited from any interested party. Comments may be in writing or may be presented orally at the hearing. Written comments must be received by the Department of Insurance no later than Friday, June 18th, 1999 and should be addressed to Fred A. Townsend, III, Deputy Insurance Commissioner, 841 Silver Lake Boulevard, Dover, DE 19904. Those wishing to testify or those intending to provide oral testimony must notify Fred A. Townsend, III at 302.739.4251, ext. 157 or 800.282.8611 no later than Friday, June 18th, 1999.
Regulation No. 83, Standards of payment for Assistants at Surgery
Section
1. Authority
2. Definitions
3. Scope
4. Purpose
5. Procedure for Payment
6. General Business Practice
7. Penalty
8. Causes of Action and Defenses
9. Effective Date
§1. Authority.
This regulation is adopted by the Commissioner pursuant to 18 Del. C. §§311, 2304(16) and 2312. It is promulgated in accordance with 29 Del. C. Chapter 101.
§ 2. Definitions.
For the purpose of this regulation, the following definitions shall apply:
a. Health insurer: health insurance companies, health maintenance organizations, health service corporations and any other entity providing a plan of health insurance or benefits subject to state insurance regulations.
b. Health Care Provider: any entity or individual licensed, certified or otherwise permitted by law to provide health care in the ordinary course of business, practice or profession.
c. Policyholder or Certificate Holder: a person covered under such policy or a representative designated by such person and entitled to services provided in the policy.
d. Assistant at Surgery: a physician, nurse practitioner, clinical nurse specialist, certified surgical technician, certified first surgical assistant, or physician assistant who is licensed and actively assists the physician in charge of a case in performing a surgical procedure.
§3. Scope.
This regulation shall apply to all health insurers as defined in Section 2 above, and shall apply to all contracts for insurance issued by these entities.
§4. Purpose.
Some surgical procedures require a primary surgeon and an assistant surgeon. Federal law sets forth guidelines for the payment, under Medicare Part B, for the services of assistants at surgery. No such guidelines exist in Delaware law, and in many cases health insurers will not pay for such services. The purpose of this regulation is to require that health insurers make payment for the services of assistants at surgery in the same manner as provided for under Medicare Part B.
§5. Guidelines for payment for the services of assistants at surgery.
a. A health insurer shall be required to make payment for the professional services of assistants at surgery. Such payment shall be made in the same manner set as forth in the Balanced Budget Act of 1997 and applicable publications issued by the Health Care Financing Administration (HCFA), including but not limited to HCFA’s regulations, the Medicare Part B Physician/Supplier Handbook, and Medicare Part B newsletters.
b. Payment for the services of an assistant at surgery shall be made only to the surgical assistant’s employer if such employer is neither a hospital or ambulatory surgical center.
§6. General Business Practice.
a. Within a 36 month period, three instances of a health insurer’s failure to pay a claim or bill for services promptly, as defined in section 5 above, shall give rise to a rebuttable presumption that the insurer is in violation of 18 Del. C. §2304(16)(f).
b. The 36 month period established in paragraph “a.” above shall be measured based upon the date the complaints are received at the Department. Each claim or bill, or portion of a claim or bill, pertaining to a single medical treatment or procedure provided to an individual policyholder that is processed in violation of this regulation shall constitute an “instance” as described in paragraph “a.” above.
§7. Penalties.
In addition to the imposition of penalties in accordance with 18 Del. C. §2312(b), any health insurer that fails to adhere to the standards contained in this regulation shall be required to pay to the health care provider or claimant, in full settlement of the claim or bill for heath care services, the amount of the claim or bill plus interest at the maximum rate allowable to lenders under 6 Del. C. §2301(a). This interest shall be computed from the date the claim or bill for services first became due.
§8. Causes of Action and Defenses.
This regulation shall not create a cause of action for any person or entity, other than the Delaware Insurance Commissioner, against a health insurer or its representative based upon a violation of 18 Del. C. §2304(16). In the same manner, nothing in this regulation shall establish a defense for any party to any cause of action based upon a violation of 18 Del. C. §2304(16).
§9. Effective Date.
This regulation shall become effective 120 days from the date signed by the Commissioner