June 17, 2020

States Advance Out-Of-Network Billing and Scope of Practice Legislation

State legislatures in Georgia and Louisiana hold hearings and advance bills that modify rules on out-of-network billing. Vermont’s House chamber advanced legislation that would relax supervision requirements for physician assistants.

Out-Of-Network Billing

In Georgia, HB 888 passed the Senate Health and Human Services Committee. The bill would require providers to collect no more than their enrollee’s deductible or other cost-sharing amount, as determined by the enrollee’s health insurance policy for emergency medical services performed by an out-of-network provider. The carrier would pay the provider the greater of:

  • The verifiable contracted amount paid by all carriers for similar services
  • The most recent verifiable amount agreed to by the carrier and out-of-network provider for the services; or
  • A higher amount as the carrier deems appropriate.

The provider or facility may request arbitration with the insurance commissioner when the out-of-network provider concludes that payment from the carrier is not sufficient.

In Louisiana, SB 7a is scheduled for a hearing before the Senate Finance Committee. The bill would require carriers to ensure that out-of-network costs for emergency services would not be greater than the in-network rates for enrollees. The amount billed would not exceed 120 percent of the usual and customary cost, defined as the 80th percentile of all charges for the particular healthcare service performed by a provider in the same specialty and provided in the same geographical area as reported in a benchmarking database maintained by a nonprofit organization specified by the insurance commissioner.

In the event of a payment dispute, payment for the dispute resolution process shall be the responsibility of the nonparticipating physician when the independent dispute resolution entity determines the health insurance issuer's payment is reasonable. Payment for the dispute resolution process shall be the responsibility of the carrier when the independent dispute resolution entity determines the nonparticipating physician's fee is reasonable. The carrier and the nonparticipating physician would evenly divide and share the prorated cost for the dispute resolution process when a good faith negotiation directed by the independent dispute resolution entity results in a settlement between the carrier and nonparticipating physician.

Scope of Practice

In Vermont, SB 128 passed the House chamber. It would remove the mandatory physician supervision of physician assistants (PAs). It would also change the current delegation agreement where the supervising physician delegates the PA’s duties and scope of practice to a collaboration agreement where a PA would consult with a physician or other healthcare professional based on the patient’s condition and the PA’s education, competencies and experience.