Ch. 348

1996 LAWS OF MARYLAND

(11) DEVELOP PRACTICE PARAMETERS FOR THE TREATMENT OF SOFT
TISSUE INJURIES AS PROVIDED IN ARTICLE 48A, § 541A OF THE CODE; AND

[(11)] (12) Reduce the costs of claims submission and the administration of
claims for health care practitioners and payors.

19-1509.

(a) (1) In this section the following words have the meanings indicated.

(2) "Code" moans the applicable current procedural terminology (CPT)
code as adopted by the American Medical Association or other applicable code under an
appropriate uniform coding scheme approved by the Commission.

(3)     "Payor" means:

(i) A health insurer or nonprofit health service plan that holds a
certificate of authority and provides health insurance policies or contracts in the State in
accordance with Article 48A of the Code or the Health—General Article;

(ii) A health maintenance organization that holds a certificate of
authority.

(4)     "Unbundling" means the use of two or more codes by a health care
provider to describe a surgery or service provided to a patient when a single, more
comprehensive code exists that accurately describes the entire surgery or service.

(b) (1) By January 1, 1997, the Commission shall implement a payment system
for all health care practitioners in the State.

(2)     The payment system established under this section shall include a
methodology for a uniform system of health care practitioner reimbursement.

(3)     Under the payment system, reimbursement for each health-care
practitioner shall be comprised of the following numeric factors:

(i) A numeric factor representing the resources of the health care
practitioner necessary to provide health care services;

(ii) A numeric factor representing the relative value of a health care
service, as classified by a code, compared to that of other health care services; and

(iii) A numeric factor representing a conversion modifier used to adjust
reimbursement.

(4)     To prevent overpayment of claims for surgery or services, in developing
the payment system under this section, the Commission, to the extent practicable, shall
establish standards to prohibit the unbundling of codes and the use of reimbursement
maximization programs, commonly known as "upcoding".

(5) In developing the payment system under this section, the Commission
shall consider the underlying methodology used in the resource based relative value scale
established under 42 U.S.C. § 1395w-4.

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