§ 14-205.2. Payments to on-call physicians and hospital-based physicians
West's Annotated Code of MarylandInsuranceEffective: July 1, 2011
Effective: July 1, 2011
MD Code, Insurance, § 14-205.2
§ 14-205.2. Payments to on-call physicians and hospital-based physicians
(a) Except as otherwise provided, this section applies to both on-call physicians and hospital-based physicians who:
(b)(1) Except as provided in paragraph (3) of this subsection, an insured may not be liable to an on-call physician or a hospital-based physician subject to this section for covered services rendered by the on- call physician or hospital-based physician.
(ii) if Medicare is the primary insurer and the insurer is the secondary insurer, any amount up to the Medicare approved or limiting amount, as specified under the federal Social Security Act, that is not owed to the on-call physician or hospital-based physician by Medicare or the insurer after coordination of benefits has been completed, for Medicare covered services rendered to the insured by the on-call physician or hospital-based physician; and
(c)(1) This subsection applies only to on-call physicians subject to this section.
1. 140% of the average rate the insurer paid for the 12-month period that ends on January 1 of the previous calendar year in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service, to similarly licensed providers under written contract with the insurer; or
2. the average rate the insurer paid for the 12-month period that ended on January 1, 2010, in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service to a similarly licensed provider not under written contract with the insurer, inflated by the change in the Medicare Economic Index from 2010 to the current year.
(d)(1) This subsection applies only to hospital-based physicians subject to this section.
1. 140% of the average rate the insurer paid for the 12-month period that ends on January 1 of the previous calendar year in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service, to similarly licensed providers, who are hospital-based physicians, under written contract with the insurer; or
2. the final allowed amount of the insurer for the same covered service for the 12-month period that ended on January 1, 2010, inflated by the change in the Medicare Economic Index to the current year, to the hospital-based physician billing under the same federal tax identification number the hospital-based physician used in calendar year 2009.
(e)(1) For the purposes of subsections (c)(2)(ii)1 and (d)(2)(ii)1 of this section, an insurer shall calculate the average rate paid to similarly licensed providers under written contract with the insurer for the same covered service by summing the contracted rate for all occurrences of the Current Procedural Terminology Code for that covered service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.
(2) For the purposes of subsection (c)(2)(ii)2 of this section, an insurer shall calculate the average rate paid to similarly licensed providers not under written contract with the insurer for the same covered service by summing the rates paid to similarly licensed providers not under written contract with the insurer for all occurrences of the Current Procedural Terminology Code for that covered service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.
(f) An insurer shall disclose, on request of an on-call physician or hospital-based physician subject to this section, the reimbursement rate required under subsection (c)(2)(ii) or (d)(2)(ii) of this section.
(g)(1) An insurer may seek reimbursement from an insured for any payment under subsection (c)(2)(ii) or (d)(2)(ii) of this section for a claim or portion of a claim submitted by an on-call physician or hospital- based physician subject to this section and paid by the insurer that the insurer determines is the responsibility of the insured based on the insurance contract.
(h)(1) An on-call physician or hospital-based physician subject to this section may enforce the provisions of this section by filing a complaint against an insurer with the Administration or by filing a civil action in a court of competent jurisdiction under § 1-501 or § 4-201 of the Courts Article.
(i) The Administration may take any action authorized under this article, including conducting an examination under Title 2, Subtitle 2 of this article, to investigate and enforce a violation of the provisions of this section.
(j) In addition to any other penalties under this article, the Commissioner may impose a penalty not to exceed $5,000 on an insurer for each violation of this section.
Credits
Added by Acts 2010, c. 537, § 1, eff. July 1, 2011.
MD Code, Insurance, § 14-205.2, MD INSURANCE § 14-205.2
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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