An Act Concerning The Burden Of Proof During Adverse Determination And Utilization Reviews.
Impact
The proposed changes could significantly affect the adjudication processes for denied medical claims and increase accountability on health insurers. By requiring health carriers to prove that services are unnecessary, the bill aspires to create a more equitable system for patients navigating coverage issues. It could encourage a more favorable environment for necessary medical services, particularly for patients seeking essential treatments that insurers might otherwise contest.
Summary
Bill SB00029 aims to amend existing regulations concerning health carriers by shifting the burden of proof during adverse determination and utilization reviews. Specifically, the bill mandates that health carriers must demonstrate that certain healthcare services are not medically necessary rather than leaving that burden on the patient or provider. This change is intended to enhance patient rights and ensure that necessary healthcare services are not unduly denied based on insurance company assessments.
Contention
Notably, the bill could lead to contention among various stakeholders in the healthcare sector. Proponents, including patient advocacy groups, argue that this bill empowers patients and improves access to critical health services. However, insurance companies may oppose the bill, claiming it could lead to increased costs and complicate the utilization review process. Concerns may also arise regarding how this shift could impact operational efficiencies within insurance companies and the overall healthcare delivery system.