Professional Rights

VII. Key Issues: Regulation & Reform >> B. Health Care Regulation >> Health Insurance Regulation >> Professional Rights

Overview

These regulations include a variety of restrictions on the use by managed care organizations (MCOs) of various provisions thought to adversely affect providers:

• “Gag clauses” prevent providers from discussing various treatment options without first discussing the case with the plan. Laws prohibiting their use in essence free the physicians to discuss all treatment options with patients, regardless of whether or not they are covered by the health plan.
• Examples of due process protections include requiring that health plans: must disclose in writing reasons for denying network membership, must give providers a hearing or opportunity to take corrective action before termination, or cannot terminate without cause.
• Prompt payment requirements require insurers to pay claims within a certain time frame, usually 45 days.