An Act Concerning The Burden Of Proof During Adverse Determination And Utilization Reviews.
This bill is expected to influence state laws concerning health insurance practices, particularly in the area of utilization reviews and adverse determinations. By placing the burden of proof on the health carriers, the bill aims to protect consumers from potential denials of necessary medical services based solely on the carriers' assertions of non-medical necessity. Additionally, patients, particularly those dealing with mental health and substance use disorders, may find this a significant safeguard in ensuring their access to critical care services.
SB00211, titled 'An Act Concerning The Burden Of Proof During Adverse Determination And Utilization Reviews', aims to shift the burden of proof onto health carriers in cases concerning adverse determinations of healthcare services. The bill asserts that healthcare services ordered by a professional within their scope of practice shall be presumed medically necessary, thus requiring the health carrier to demonstrate otherwise. This provision seeks to enhance transparency and fairness in the healthcare decision-making process, particularly for patients undergoing significant medical scrutiny.
While supporters argue that the bill provides necessary protections for patients and addresses issues of equity in healthcare access, there are potential points of contention. Opponents may raise concerns regarding the implications for health carriers, fearing that increased burdens could lead to higher operational costs, which might be passed on to consumers in the form of increased premiums. Furthermore, the potential for varied interpretations of medical necessity could lead to disputes, complicating the healthcare delivery and insurance reimbursement landscape.