States are Looking to Sanction Payers for Denials

States are closely scrutinizing payers who are frequently denying treatments. The California senate has recently put forward SB 363, a bill that could bring about significant changes in the reporting and accountability systems for health care service plans and health insurers in California.

What the bill does

The bill requires healthcare service plans and health insurers to report treatment denials and modifications annually, compare these reports with independent medical review outcomes, and imposes penalties for excessive denials or modifications.

The bill’s requirement for annual reporting of treatment denials and modifications aims to increase transparency and accountability. By mandating that these reports be separated by type of care, such as preventive, acute, and chronic care, and disaggregated by age groups, like children, adults, and seniors, the bill ensures a detailed and comprehensive overview of the treatment decisions made by healthcare service plans and insurers.

A pivotal aspect of SB 363 is the comparison of treatment denials and modifications with independent medical review outcomes. This provision is a powerful tool that ensures healthcare service plans and insurers are held accountable for their treatment decisions, marking a significant shift in the power dynamics of the healthcare system.

Penalties would be imposed on the health plan.

The administrative penalties outlined in SB 363 are substantial, starting at $50,000 for the first violation and reaching $1,000,000 for each subsequent violation. These penalties, while significant, underscore the fairness and integrity of the bill’s provisions, ensuring that healthcare service plans and insurers adhere to fair and just treatment practices.