Mentor Research Institute

Healthy Contracts Legislation; Measurement & Value-Based Payment Contracting: Online Screening & Outcome Measurement Software

503 227-2027

Draft Legislation for the Implementation of Healthy Contracts Requirements

A Discussion Paper

Following is a summary of a Legislator Draft Request available from Mentor Research Institute by request.

Title: An Act to Ensure Transparency, Accountability, and Integrity in Value-Based Payment Contracts for Mental and Behavioral Health Services

Section 1: Purpose

The purpose of this Act is to ensure that value-based payment contracts for mental and behavioral health services are transparent, accountable, and free from fraud. This Act mandates the implementation of Independent Certified Internal Auditors’ contract oversight, the establishment of ethics point portals, and the requirement that all contracts for value-based payment for mental and behavioral health services and their relevant policies and their relevant policies be written in plain, understandable language.

Section 2: Definitions

1.   Healthplan: Any organization that provides health insurance or health benefits to enrolled members.

2.   Independent Certified Internal Auditor (CIA): A professional auditor certified by a recognized accrediting body, such as the Institute of Internal Auditors, who is not part of the Healthplan’s management and has no conflicts of interest.

3.   Ethics Point Portal: A secure, anonymous platform for reporting unethical practices, non-compliance, and other concerns related to Healthplan operations.

4.   Value-Based Payment Contract: A contract that ties reimbursement to the value of care. The Oregon Health Authority defines value as evidence-based, patient-centered, increased quality and improved outcomes and health.

Section 3: Independent Certified Internal Auditors

1.   Appointment and Role: (a) Healthplans must engage one or more Independent Certified Internal Auditors. (b) CIAs must report directly to the Healthplan audit committee or the board of directors of the Healthplan, not to operational management. The CIA may inform the CEO. (c) CIAs will be responsible for monitoring the Healthplan’s practices to ensure they do not undermine mental and behavioral Health service quality, access, outcomes, or medically necessary and reasonable care. (d) CIAs will conduct regular audits to detect and prevent fraud, ensuring compliance with all relevant laws and regulations.

2.   CIAs’ Responsibilities: (a) Evaluate the design and effectiveness of internal controls. (b) Ensure the Healthplan's practices align with state, federal, and industry guidelines and best practices. (c) Report findings and recommendations to the Healthplan’s audit committee or board of directors. (d) Ensure implementation of transparent shared values, objectives, controls, key leading indicators, rigorous tests of design and effectiveness, a risk impact analysis (RIO), a risk control matrix (RCM), and inherent risk analysis..

Section 4: Ethics Point Portal

1.   Establishment: (a) Healthplans must each establish and maintain an ethics point portal allowing anonymous reporting of unethical practices and non-compliance. (b) The portal must be accessible to all stakeholders, including providers, employees, and patients.

2.   Operation: (a) The portal must allow for secure and confidential reporting. (b) Healthplans must ensure reports are reviewed promptly and appropriate action is taken. (c) Summary reports of the issues raised, and actions taken must be presented to the Healthplan’s audit committee or board of directors no less than quarterly.

Section 5: Plain and Understandable Language in Contracts and Policies

1.   Requirements: (a) All contracts and policies related to value-based payment must be written in plain and understandable language. (b) Contracts must include clear definitions, obligations, performance metrics, and terms of reimbursement to ensure all parties can easily comprehend the requirements.

2.   Implementation: (a) Healthplans must review and revise existing contracts and policies related to value-based payment to comply with this requirement. (b) All new contracts and policies related to value-based payment must be drafted to meet this standard.

Section 6: Enforcement and Compliance

1.   Oversight: (a) The state’s regulatory authority will oversee the implementation and compliance of this Act. (b) Healthplans must submit annual compliance reports to the state’s regulatory authority, detailing their adherence to the requirements of this Act.

2.   Penalties: (a) Healthplans found in violation of this Act may be subject to fines, sanctions, or other penalties as deemed appropriate by the state’s regulatory authority. (b) Continued non-compliance may result in suspension or revocation of the Healthplan’s operating license.

Section 7: Effective Date

This Act shall take effect on [Date], and Healthplans must comply with all provisions within six months of the effective date.

Section 8: Severability

If any provision of this Act is found to be unconstitutional or otherwise invalid, the remaining provisions shall not be affected and will continue in full force and effect.

Section 9: Legislative Intent

It is the intent of the Legislature that this Act be liberally construed to effectuate its purposes.

Section 10: Legislative Findings

The Legislature finds that ensuring transparency, accountability, and integrity in value-based payment contracts for mental and behavioral health services is essential to protect public funds, improve access to quality healthcare, and maintain public trust.

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Key words: Supervisor education, Ethics, COVID Office Air Treatment, Mental Health, Psychotherapy, Counseling, Patient Reported Outcome Measures,