New Health Care Provider Information Form

February 19, 2003 Bulletin No. 17-98 TO: HEALTH CARE PROVIDERS FROM: ARKANSAS INSURANCE DEPARTMENT SUBJECT: COMMISSIONER'S INFORMATIONAL BULLETIN: NEW HEALTH CARE PROVIDER INFORMATION FORM The mission of the Arkansas Insurance Department is consumer protection through insurer financial solvency (analyzing and auditing insurer books to make sure insurers are financially secure enough to make their payment obligations to policyholders) and market conduct (e.g., policy claims handling practices) regulation. While the Insurance Department has regulatory authority over approximately 22% (one-fifth (1/5)) of the health plans in the marketplace, by law we only have jurisdiction to police the contract between the insured and the insurer, not the separate contract between the provider and the insurer. The law believes that providers generally are more legally-sophisticated people who may deal with insurers at arms-length and on near-equal footing. Generally speaking, this Department does not have jurisdiction over self-insured health plans, or plans organized pursuant to the federal Employees' Retirement Income Security Act ("ERISA"), although we do register Third-Party Administrators ("TPA's"). The Arkansas Department of Health also shares some jurisdiction with the Arkansas Insurance Department in the regulation of the healthcare marketplace. Pursuant to Arkansas law, the Department of Health is responsible for ensuring, as much as is humanly possible, equal access to, and quality of care of, healthcare services. If the Health Department believes there exists a true access or quality of care issue as a result of insurers' activities, it may take actions it deems appropriate and necessary. The Insurance Department does not have legal jurisdiction or authority to handle complaints from medical providers about insurers, or to act as a collection agency for medical providers. However, we recognize that, generally speaking, if a provider is having problems with an insurer, consumers most likely are having similar problems with the insurer. We also recognize that medical providers are in a position to provide this Department with a great deal of useful information which may be helpful to us in performing our statutorily mandated consumer market conduct regulatory activities. Therefore, attached to this Bulletin, please find a Health Care Provider Information Form for your use in making us aware of such problems. Please be advised that this Department only has legal jurisdiction to investigate and resolve complaints about insurers from consumers. We may not accept consumer complaints directly Arkansas Insurance Department Page 2 of 2 Bulletin No. 17-98 from providers. If you have a patient that has a specific insurance-related problem with an insurer, the patient should contact our Consumer Services Division at (800) 852-5494 or (501) 371-2640. Alternatively, the consumer may complete a complaint form and mail it to the Consumer Services Division. (Consumer complaint forms may be obtained by calling our Consumer Services Division at the above number.) Please understand there are legal reasons the consumer must be willing to file and actively pursue a complaint with this Department in order for us to act effectively upon it. Therefore, it is imperative the patient/consumer file a complaint and be willing to actively pursue it with this Department in order for us to take formal action on it. Moreover, please keep in mind that, pursuant to Arkansas law an insurer generally has forty-five (45) days to pay a claim for medical services. This deadline may be extended to "a reasonable time" in some limited situations (e.g., where the insured or provider has not provided required, necessary documentation or in coordination of benefit situations). In most cases provider business office personnel should communicate clearly, work closely and cooperate with insurers to effect timely payment of claims without the necessity of intervention from this Department. Again, we do not have the legal jurisdiction or personnel necessary to respond to each and every medical provider complaint we will receive. However, we will use the information you provide to make us aware of any issues which could have a direct, adverse effect upon consumers. Of course, we can and will respond to and investigate complaints from consumers with health plans that fall within our regulatory jurisdiction. It is our desire to help your patient obtain payment of any and all claims which should be paid under the terms of their specific health insurance contract. Therefore, we look forward to working with you in this regard. If you have any questions regarding this Bulletin, please contact the Arkansas Insurance Department Consumer Services Division at (501) 371-2640 or (800) 852-5494. ________________________________ Mike Pickens State Insurance Commissioner MP:sc