Discontinuance of the Mandatory Second Opinion Program (SOP); Notice of Rule Change [27 Pa.B. 1608] The Department of Public Welfare announces that effective March 15, 1997, recipients will no longer be required to obtain a mandatory second opinion for the sixteen major procedure categories established under this program. This Rule Change will be adopted by final rulemaking to 55 Pa. Code §§ 1150.2, 1150.59, and 1150.60, relating to the second opinion program.
The Department's contract with Keystone Health Plan West (KHPW) to administer the second opinion program will be terminated effective April 30, 1997. Therefore, all second opinions obtained through KHPW must be completed by April 30, 1997.
This Rule Change has been reviewed by the Office of General Counsel and the Office of Attorney General.
This Rule Change is made under the Joint Committee on Documents Resolution 1996-1 (3) 26, No. 20, Pa.B. 2374 and will be in effect for 365 days pending adoption of final rulemaking by the Department.
Public comments to this Rule Change can be made by contacting: Department of Public Welfare, Office of Medical Assistance Programs c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120.
Persons with a disability may use the AT&T Relay Service by calling 1 (800) 654-5984 (TDD users) or 1 (800) 654-5988 (voice users). If you require another alternative format, contact Thomas Vracarich at (717) 783-2209.
FEATHER O. HOUSTOUN,
SecretaryPurpose
The purpose of this notice is to provide notification of the discontinuance of the mandatory Second Opinion Program (SOP). Effective March 15, 1997, recipients will no longer be required to obtain a mandatory second opinion for the surgical procedures established under this program.
Scope
This notice applies to all acute care hospitals, short procedure units, free-standing ambulatory surgical centers, rural health clinics, physicians, dentists, and podiatrists enrolled in the Medical Assistance Program.
Background/Discussion
Since March 1, 1989, the Department has required medical assistance recipients to obtain a mandatory second opinion for sixteen major procedure categories. These procedures include:
Bunionectomy
Cataract surgery, except congenital
Coronary angioplasty
Hip replacement
Knee surgery
Myringotomy with tubes
Spinal and vertebral surgery
Tonsillectomy with or without adenoidectomy
Carotid endarterectomy
Coronary artery bypass
Hemorrhoidectomy
Hysterectomy
Mastectomy
Prostatectomy
Submucous resection
Varicose vein strippingThe Department's contract with Keystone Health Plan West (KHPW) to administer the SOP terminates on April 30, 1997. Therefore, all second opinions obtained through KHPW must be completed by April 30, 1997.
Procedure
The Department encourages recipients to seek second opinions to obtain additional information regarding treatment options. Fee-for-service recipients may elect to seek a voluntary second opinion by referral from their primary care physician or by locating a provider through their own initiative. Recipients can request aid in locating a physician to provide a second opinion from their local county assistance office or local hospital physician referral service. Recipients enrolled in a managed care plan should discuss this option with their assigned primary care physician or health maintenance organization member services representative.
Policy
Effective May 1, 1997, Chapter 1150 (Medical Assistance Program Payment Policies) will be amended as follows:
§ 1150.2. Definitions.
* * * * * [SECOND OPINION PROGRAM--A process through which MA recipients receive the opinion of a second practitioner when there is a question as to the medical necessity or appropriateness of a procedure or if the procedure appears on the Department's list of procedures that automatically requires a second opinion as published as a statement of policy in the Pennsylvania Bulletin.]
* * * * * § 1150.59. PSR Program.
* * * * * (g) Within 3 working days of receiving a place of service review request, the Department will do one of the following:
(1) Certify the request.
(2) Ask for additional information in order to certify the request as specified under subsection (h).
[(3) Request a second opinion as specified under subsection (i).]
(h) If the Department requests additional information under subsection (g), the provider will have 14 days to provide the Department with the information to have the PSR process completed. If the requested information is not received by the Department within 14 days, the provider shall reapply for certification.
[(i) Before the certification of PSR is completed, a second opinion shall be obtained if one of the following conditions exist:
(1) The procedure is on the mandatory second opinion list published by the Department.
(2) After review, the Department's physician questions the medical necessity of performing the procedure.
(j) If a second opinion is required under § 1150.60(a) (relating to second opinion program) a practitioner or facility may not request a PSR until he has documentation available, as specified in the provider handbook, that the recipient has obtained a second opinion.]
(i) [(k)] To be eligible for payment for an admission or procedure to a PSR, a facility or practitioner shall comply with the instructions in the provider handbook. Failure to comply with PSR procedures [and applicable second opinion procedures in § 1159.60 (relating to second opinion program)] in § 1150.59 will result in a payment equal to 50% of the MA approved reimbursement amount for services provided by the admitting practitioner and facility.
* * * * * § 1151.60. [Second opinion program.] Reserved.
[(a) Except as specified in subsection (h), a practitioner is required to refer a recipient to the Department to arrange an appointment for a second opinion when the proposed procedure is one that automatically requires a second opinion.
(b) The Department will publish a statement of policy to be codified at § 1150.60(a) (relating to second opinion consultation--statement of policy) listing the procedures which automatically require a second opinion. Revisions or updates to this list will also be published as a statement of policy in the Pennsylvania Bulletin.
(c) The Department may require a recipient to obtain a second opinion if the Department's physicians question the medical necessity of performing the procedure through the PSR Program under § 1150.59 (relating to PSR Program).
(d) The Department will provide the recipient with the names of practitioners within the recipient's vicinity who are approved to provide a second opinion. The Department will arrange an appointment with the practitioner the recipient chooses. The arrangement for the appointment will be completed no later than 6 working days after the request by the recipient or the recipient's agent.
(e) After the recipient obtains a second opinion, the final decision on whether or not to have the procedure performed will be made by the recipient, even if the second opinion is contrary to the opinion of the attending practitioner. If the recipient decides to undergo the procedure, the Department will make payment in accordance with the Department's applicable payment regulations.
(f) If the recipient fails to obtain a second opinion required in subsection (a) or subsection (c), the Department will not precertify the admission.
(g) A second opinion is not required if one of the following conditions applies:
(1) The procedure is documented in the recipient's medical record as an emergency or urgent admission by the attending practitioner and that immediate or prompt surgery is medically indicated.
(2) The patient is enrolled in a comprehensive health services plan or a capitated physician case management program.
(3) The patient is also covered by another health insurance and has obtained a second opinion under that program for the procedure for which MA coverage is sought.
(4) Another health insurance is expected to make payment for the service and MA is not expected to make an additional payment.
(5) The patient was not eligible for MA at the time the procedure was performed but subsequently became eligible.
(6) The Department has approved the admission of a recipient to a hospital and during the hospital stay it is determined that the recipient needs a surgical procedure that would otherwise require a second opinion under subsection (a) or (c).
(h) The Department will grant a waiver of the second opinion requirement specified in subsection (a) if the Department determines that one of the following applies:
(1) No qualified practitioner is available to give a second opinion.
(2) The recipient would have to travel more than 50 miles to obtain a second opinion.
(3) The recipient's medical condition is such that the travel to obtain a second opinion would result in a medical hardship for the recipient, such as when the recipient's medical condition confines the recipient to his home environment.]
Fiscal Note: 14-NRC-070. No fiscal impact; (8) recommends adoption. This regulatory action provides public notice that, effective March 15, 1997, Medical Assistance recipients will no longer need to obtain a mandatory second opinion for 16 major surgical procedures. Discontinuance of the contract costs associated with the program is expected to produce savings in the Medical Assistance-Inpatient Appropriation of $1,398,000 annually beginning in fiscal year 1997-98.
[Pa.B. Doc. No. 97-485. Filed for public inspection March 28, 1997, 9:00 a.m.]
