Downcoding medical claims.
Vote required
Majority
Fiscal committee
No
Appropriation
No
Current location
Appropriations
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Progress
Where this bill stands in the legislative process.
- Introduced
- Passed Assembly
- Passed Senate
- To Governor
- Became Law
Overview
This bill aims to protect healthcare providers and patients by preventing health care service plans and insurers from unilaterally altering medical claim codes (downcoding) to receive lower payments. It requires a documented clinical review and a clear dispute process when downcoding occurs, and prohibits discriminatory downcoding practices against providers who treat complex patients. The bill also mandates data collection and reporting on coding and claims adjustment practices to assess their impact on the healthcare system.
Key provisions
- Prohibits automated downcoding of medical claims by health care service plans and insurers.
- Requires a documented clinical review for all downcoding decisions.
- Mandates clear notification and dispute resolution processes for providers when claims are downcoded.
- Prohibits discriminatory downcoding targeting providers of complex patients.
- Requires data collection and reporting on coding and claims adjustment practices.
- Establishes penalties for violations of the bill's provisions.
Who is affected
- Health care service plans
- Health insurers
- Physicians
- Other healthcare providers
- Patients
Notable changes
- Adds specific requirements for clinical documentation and justification for downcoding decisions.
- Creates a formal process for providers to dispute downcoded claims.
Bill text
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Sponsors
Official sponsors from legislative records.
2 on record
Primary sponsor
Cosponsor
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