(a) On or before July 1, 1999, for purposes of public disclosure, every disability insurer that covers hospital, medical, or surgical expenses, and authorizes insureds to select providers who have contracted with the insurer for alternative rates of payment as described in Section 10133, and the disability insurer or any of its contracting providers or provider groups utilize economic profiling related to services provided to insureds, shall file with the department a description of any policies and procedures related to economic profiling utilized by the insurer and any of its contracting providers and provider groups. The filing shall describe how these policies and procedures are used in utilization review, peer review, incentive and penalty programs, and in provider retention and termination decisions. The filing shall also indicate in what manner, if any, the economic profiling system being used takes into consideration risk adjustments that reflect case mix, type and severity of patient illness, age of patients, and other policyholder characteristics that may account for higher or lower than expected costs or utilization of services. Any changes to the policies and procedures shall be filed expeditiously with the commissioner. Nothing in this section shall be construed to restrict or impair the department, in its discretion, from utilizing the information filed pursuant to this section for purposes of ensuring compliance with this chapter.
(b) The commissioner shall make each disability insurer filing available to the public upon request. The commissioner shall not publicly disclose any information submitted pursuant to this section that is determined by the commissioner to be confidential pursuant to state law.
(c) Each disability insurer that uses economic profiling shall, upon request, provide a copy of economic profiling information related to a contracting provider or provider group to the profiled provider or group. In addition, each disability insurer shall require as a condition of contract that its contracting provider groups that maintain economic profiles of individual providers who may be selected by insureds shall, upon request, provide a copy of individual economic profiling information to individual providers who are profiled. The economic profiling information provided pursuant to this section shall be provided upon request until 60 days after the date upon which the contract between the insurer and the individual provider or provider group terminates, or until 60 days after the date the contract between the provider group and the individual provider terminates, whichever is applicable.
(d) For the purposes of this section, “economic profiling” shall mean any evaluation of a particular physician, provider, or provider group based in whole or in part on the economic costs or utilization of services associated with medical care provided or authorized by the physician, provider, or provider group.
(Added by Stats. 1998, Ch. 893, Sec. 2. Effective January 1, 1999.)
Last modified: October 25, 2018