Breast Cancer Screening
- For women ages 35 to 39, including an annual baseline mammogram;
- An annual mammogram for women over age 30, deemed by a licensed physician or clinician to have an above-average risk for breast cancer; and
- For women of any age, any additional or supplemental imaging, such as breast magnetic resonance imaging or ultrasound, deemed medically necessary by an applicable American College of Radiology® guideline.
Additionally, providers of healthcare services specified under this section would be reimbursed at rates accurately reflecting the resource costs specific to each modality, including any increased resource cost as of Jan. 1, 2021.
The bill would expand the definition of “low-dose mammography” to include both digital mammography and digital breast tomosynthesis, and interpreting and rendering a report by a radiologist or other physician based on the screening. Digital breast tomosynthesis would be defined as: the means a radiologic procedure that allows a volumetric reconstruction of the whole breast from a finite number of low-dose two¬-dimensional projections obtained by different X-ray tube angles, creating a series of images forming a three-dimensional representation of the breast.
The House bill has been pre-filed and the Senate version has been formally introduced.
HB 309 was also pre-filed and would similarly expand the coverage mentioned above, provided the woman has an above-average risk for breast cancer as determined by using a risk-factor modeling tool. It defines digital breast tomosynthesis as, “A radiologic procedure that involves the acquisition of a projection of images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.”
In Kansas, SB 48 was referred to the Senate Committee on Insurance. The bill would mandate coverage for breast cancer diagnostic examinations defined as, “A medically necessary and appropriate examination, as determined by an authorized healthcare professional for breast cancer to evaluate an abnormality in the breast.” Screening would be covered for abnormalities that are:
- Seen or suspected from a breast cancer screening examination;
- Detected by another means of examination; or
- Suspected based on the medical or family medical history of the individual.
Screenings would include examinations used to evaluate an abnormality in a breast using diagnostic mammography, MRI or ultrasound.
Out-Of-Network (OON) Billing
In New York, S 2521 was referred to the Health Committee. The bill would require healthcare facilities to provide enrollees a consolidated itemized bill within seven days of the enrollee’s discharge or release of treatment. Providers would be required to use the Uniform Patient Financial Liability Form which would be developed by the state’s insurance commissioner. The form would disclose to enrollees whether services, supplies and drugs are in-network or out-of- network, whether the care is covered by a third-party payer and the nature and amount of the patient’s projected financial liability.
In Tennessee, SB 1 and HB 2 would require the state insurance commissioner to establish an independent dispute resolution process to resolve disputes regarding bills for out-of-network emergency services. The commissioner would promulgate rules establishing standards for the independent dispute resolution process, including a process for certifying and selecting independent dispute resolution entities.
In determining the appropriate amount to pay for a healthcare service, an independent dispute resolution entity would not consider:
- Any benchmarking database that includes Medicare or Medicaid reimbursement rates; or
- Medicare or Medicaid reimbursement rates.
An out-of-network facility-based physician, healthcare facility, or health carrier may submit a dispute regarding a fee or payment for emergency services for review to an independent dispute resolution entity. The independent dispute resolution entity would decide on a reasonable fee for the services rendered within 30 days of receipt of the dispute for review.
When determining a reasonable fee for the services rendered, the independent dispute resolution entity would select either the health carrier payment or the out-of-network facility-based physician's fee.
If an independent dispute resolution entity determines, based on the health carrier's payment and the out-of-network facility-based physician's fee, that a settlement between the health carrier and out-of-network facility-based physician is reasonably likely, or that both the health carrier's payment and the out-of-network facility-based physician's fee represent unreasonable extremes, then the independent dispute resolution entity may direct both parties to attempt a good faith negotiation for settlement. In that case, the health carrier and out-of-network physician may be granted up to 10 business days for negotiation, which runs concurrently with the 30-day period for dispute resolution. An out-of-network facility-based physician may request, and the independent dispute resolution entity may permit, that claims of a physician involving the same health carrier be aggregated and submitted for simultaneous review by an independent dispute resolution entity when the specific reason for nonpayment of the claims aggregated involve a dispute regarding a common substantive question of fact or law.
If a balance bill is received by an enrollee for elective services does not assign benefits, or who is uninsured, then the enrollee may submit a dispute regarding the balance bill for review to an independent dispute resolution entity that shall determine a reasonable fee for the services rendered.
For disputes involving an enrollee:
- When the independent dispute resolution entity determines the health carrier's payment is reasonable, the out-of-network facility-based physician or healthcare facility would pay for arbitration; and if the entity determines the out-of-network facility-based physician's or healthcare facility's fee is reasonable, the carrier would pay for arbitration.
- When a good faith negotiation directed by the independent dispute resolution entity results in a settlement between the carrier and the out-of-network facility-based physician or healthcare facility, the carrier and the out-of-network facility-based physician or healthcare facility shall evenly divide and share the prorated cost of the dispute resolution.
Both bills passed their first reading in their respective chambers.
Scope of Practice
In Connecticut, HB 5405 was referred to the Joint Committee on Public Health. The bill seeks to permit advanced practice registered nurses to perform fluoroscopy services.
In Indiana, SB 366 was referred to the Committee on Health and Provider Services. The bill seeks to change the physician supervision of physician assistants (PAs) to a collaborating agreement. It would also permit PAs to plan and initiate a therapeutic regimen including, but not limited to, ordering and prescribing diagnostic support services.
In Virginia, there will be a hearing before the House Health, Welfare and Institutions Committee on HB 2039. The measure seeks to change the practice agreement between a physician assistant and physician to a collaborative agreement. Additionally, the physician in the collaborative agreement would not be liable for the actions or inactions of the PA.