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VETOES
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H.B. 138
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[19-136.
(a) (1) In this section the following words have the meanings indicated.
(2) "Code" means 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 the Insurance Article or the Health - General Article; or
(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, 1999, 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.
(6) The Commission and the licensing boards shall develop, by
regulation, appropriate sanctions, including, where appropriate, notification to the
Insurance Fraud Unit of the State, for health care practitioners who violate the
standards established by the Commission to prohibit unbundling and upcoding.
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- 4292 -
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