July 22, 2021

Massachusetts and New York Take Aim at Out-of-Network Billing Provisions

A Massachusetts Senate committee deliberates a bill defining guidelines on medical necessity while New York issues a final regulation modifying out-of-network claims practices.

In Massachusetts, Senate Bill 645 will be heard before the Joint Committee on Financial Services. The bill would mandate that carriers cover healthcare services ordered by a physician if the services are covered under the enrollee’s health benefit plan and are medically necessary. A carrier may develop guidelines to be used in applying the standard of medical necessity. The carrier’s guidelines in making coverage determinations must be:
• Developed with input from practicing physicians and participating providers in the carrier's or utilization review organization's service area.
• Developed under the standards adopted by national accreditation organizations.
• Updated at least biennially or more often as new treatments, applications and technologies are adopted as generally accepted professional medical practice.
• Evidence-based, if practicable.

The New York State Department of Financial Services issued final regulation No. DFS-43-19-00017-A that amends Title 23 of the state’s codes, rules and regulations. For out-of-network provider claims, carriers must advise the enrollee that the claim could be a surprise bill and that the enrollee should contact the healthcare plan or visit the healthcare plan's website for additional information. If the carrier determines the out-of-network provider’s services at an in-network hospital are not emergency services and makes an adverse determination pursuant to Insurance Law or Public Health Law Article 49, the carrier shall include in the initial and final adverse determination a notice that the services may be a surprise bill and could be eligible for the dispute resolution process.

If an out-of-network physician bills a patient for emergency services or a surprise bill, the physician shall provide to the patient: a claim form; an assignment of benefits form as prescribed by the state superintendent; and a consumer disclosure information form as directed by the superintendent.

The rule takes effect Aug.13.

For more information, please contact Tina Getachew or Eugenia Brandt. To stay current on state legislative developments relevant to radiology, view the American College of Radiology® policy map.