Insurance Protocols

Insurance companies use statistics to define protocols for the average patient and the statistically most cost effective treatment. These results in rules requiring doctors to get approvals from insurance companies to do procedures or prescribe certain drugs hinder doctors' ability to provide good timely care. Insurers are in the business of making cost effective health care decisions. Insurers often require doctors to get approvals before they can authorize certain types of care in an attempt to save costs and prevent unnecessary procedures. On average, this can be cost effective for the insurance policy. However, for many, those decisions result is slower treatment, worse outcomes, and adverse side effects.

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HIGH MEDICAID FACILITY

  (F) HIGH MEDICAID FACILITY DESCRIBED.—oAs added
by section 1106(2)(D) of HCERA. A high Medicaid facility
described in this subparagraph is a hospital that—
(i) is not the sole hospital in a county;
(ii) with respect to each of the 3 most recent
years for which data are available, has an annual percent
of total inpatient admissions that represent inpatient
admissions under title XIX that is estimated to
be greater than such percent with respect to such admissions
for any other hospital located in the county
in which the hospital is located; and
(iii) meets the conditions described in subparagraph
(E)(iii).
(G) PROCEDURE ROOMS.—In this subsection, the term
‘procedure rooms’ includes rooms in which catheterizations,
angiographies, angiograms, and endoscopies are performed,
except such term shall not include emergency
rooms or departments (exclusive of rooms in which catheterizations,
angiographies, angiograms, and endoscopies
are performed).
(H) PUBLICATION OF FINAL DECISIONS.—Not later than
60 days after receiving a complete application under this
paragraph, the Secretary shall publish in the Federal Register
the final decision with respect to such application.
(I) LIMITATION ON REVIEW.—There shall be no administrative
or judicial review under section 1869, section
1878, or otherwise of the process under this paragraph (including
the establishment of such process).
(4) COLLECTION OF OWNERSHIP AND INVESTMENT INFORMATION.—
For purposes of subparagraphs (A)(i) and (D)(i) of paragraph
(1), the Secretary shall collect physician ownership and
investment information for each hospital.
(5) PHYSICIAN OWNER OR INVESTOR DEFINED.—For purposes
of this subsection, the term ‘physician owner or investor’
means a physician (or an immediate family member of such
physician) with a direct or an indirect ownership or investment
interest in the hospital.
(6) CLARIFICATION.—Nothing in this subsection shall be
construed as preventing the Secretary from revoking a hospital’s
provider agreement if not in compliance with regulations
implementing section 1866.’’.
(b) ENFORCEMENT.—
(1) ENSURING COMPLIANCE.—The Secretary of Health and
Human Services shall establish policies and procedures to ensure
compliance with the requirements described in subsection
(i)(1) of section 1877 of the Social Security Act, as added by
subsection (a)(3), beginning on the date such requirements first
apply. Such policies and procedures may include unannounced
site reviews of hospitals.
(2) AUDITS.—Beginning not later than May 1, 2012, the
Secretary of Health and Human Services shall conduct audits
to determine if hospitals violate the requirements referred to
in paragraph (1). oAs revised by section 10601(b).

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