SF 302

as introduced - 87th Legislature (2011 - 2012) Posted on 02/23/2012 08:38am

A bill for an act
relating to insurance; regulating dental plan contracts and provider audits;
amending Minnesota Statutes 2010, sections 62Q.76, by adding a subdivision;
62Q.78, by adding subdivisions.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2010, section 62Q.76, is amended by adding a
subdivision to read:

new text begin Subd. 8. new text end

new text begin Dental plan contract. new text end

new text begin "Dental plan contract" means a written agreement
between a dentist or dental clinic and dental organization to provide dental care services.
new text end

Sec. 2.

Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
to read:

new text begin Subd. 4. new text end

new text begin Dental plan contract period. new text end

new text begin A dental plan contract between a dental
organization and a dentist or dental clinic may not exceed three years. A contract that
is altered or amended by a dental organization within the three-year period may be
substituted for a current contract but is not effective without the written consent of a
dentist or dental clinic. The dentist must receive a copy of the proposed contract for
renewal along with a disclosure by the dental organization of all material changes in terms
of the contract or methods of reimbursement from the previous contract.
new text end

Sec. 3.

Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
to read:

new text begin Subd. 5. new text end

new text begin Contract amendment. new text end

new text begin An amendment or change in terms of an existing
contract between a dental organization and a dentist must be disclosed to the dentist at
least 120 days before the effective date of the proposed change. A change to a provider's
fee schedule is not an amendment or change in terms for purposes of this section. A
dental organization may not alter or amend a dental plan contract, or impose an additional
contractual obligation on a dentist or dental clinic, unless the dental organization complies
with the requirements of this subdivision.
new text end

Sec. 4.

Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
to read:

new text begin Subd. 6. new text end

new text begin Provider audits. new text end

new text begin (a) A dental organization is prohibited from recovering
payments or otherwise withholding payments from a provider.
new text end

new text begin (b) Notwithstanding paragraph (a), a dental organization may recover payments or
withhold payments from a provider after an audit or investigation where the following
circumstances are met:
new text end

new text begin (1) the dental organization has conducted an audit or investigation of the provider's
actual patient records and claims submissions, reviewed all relevant information and
documentation, and made verified findings following the audit or investigation;
new text end

new text begin (2) looks back no more than two years from the date the audit or investigation
results are given to the provider; and
new text end

new text begin (3) the payments or withholding amount do not rely, in any way, on mathematical
extrapolation or other statistical modeling.
new text end

new text begin (c) If a dental organization conducts a provider audit, the dental organization must
use a licensed Minnesota dentist, who continues to practice chair-side and whose license
is in good standing, to review the charts.
new text end

new text begin (d) If a dental organization undertakes a provider audit, as referenced in this
subdivision, and determines that payments have been made to a provider for a noncovered
service, the dental organization must issue new explanation of benefit forms advising
patients that they may be responsible for the full amount of the noncovered service.
new text end

new text begin (e) Payments recovered by a dental organization as a result of a provider audit must
be returned to the entity that sponsored the plan.
new text end

new text begin (f) As part of any provider audit process, a dental organization shall:
new text end

new text begin (1) provide a written explanation to the provider of the reason for the audit and the
process the dental organization intends to use to audit the patient charts, as well as a
written explanation of the processes available to the provider once the dental organization
completes its review of the audited patient records;
new text end

new text begin (2) allow the provider at least 120 days from the date that the provider receives the
verified audit or investigation findings to review, meet, and negotiate a potential informal
resolution to the audit or investigation; and
new text end

new text begin (3) not be allowed to assess or otherwise require the provider to reimburse the dental
organization for its internal administrative costs, external consultant expenses, attorney
fees, or other costs incurred in conjunction with any audit or investigation.
new text end

new text begin (g) For the purpose of this section, fraud means an intentional deception
or misrepresentation a dentist or dental clinic makes knowing the deception or
misrepresentation could result in an unauthorized benefit or reimbursement. Abuse
means an incident or practice of a dentist or dental clinic that is inconsistent with
accepted business or financial practices and which results in unnecessary cost to a dental
organization.
new text end

Sec. 5.

Minnesota Statutes 2010, section 62Q.78, is amended by adding a subdivision
to read:

new text begin Subd. 7. new text end

new text begin Payment for covered services. new text end

new text begin (a) Notwithstanding any other provisions
of law, no dental plan or dental provider agreement of a dental organization contracting
for the provision of dental care services may require, directly or indirectly, that a dentist
who is a participating provider provide services to an enrolled participant at a fee set by,
or at a fee subject to the approval of, the dental plan or dental organization, unless the
dental services are covered services.
new text end

new text begin (b) A health care service contractor or other person providing third-party
administrator services shall not make available any providers in its dentist network to a
plan that sets dental fees for any services except covered services.
new text end

new text begin (c) For purposes of this section, "covered services" means dental care services for
which a reimbursement is available under an enrollee's plan contract.
new text end

Sec. 6. new text begin EFFECTIVE DATE.
new text end

new text begin Sections 1 to 5 are effective August 1, 2011, and apply to dental plans and provider
agreements entered into or renewed on or after that date.
new text end