June 07, 2018

Missouri Secures Tomosynthesis Coverage

Before his May 29 resignation, embattled Missouri Gov. Eric Greitens signed HB 1252, requiring health care insurers to provide benefits or coverage for low-dose mammography screening and expanding the state’s legal definition of now mandated breast tomosynthesis.

The term “low-dose mammography screening” was revised to include digital mammography and breast tomosynthesis and defines breast tomosynthesis as “a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross sectional digital three-dimensional images of the breast.” Furthermore, the new law stipulates that on and after January 1, 2019, providers of low-dose mammography screening “shall be reimbursed at rates accurately reflecting the resource costs specific to each modality, including any increased resource cost of breast tomosynthesis.”

The governor also signed SB 982 into law. It stipulates payment provisions on "unanticipated out-of-network (OON) care", health care services received by a patient in an in-network facility from an out-of-network health care professional from the time the patient presents with an emergency medical condition until the time the patient is discharged.

SB 982 requires that OON emergency services necessary to screen and stabilize a patient shall be paid directly to the health care provider and within 180 days of providing unanticipated OON care. A provider may send any claim for charges incurred for the care to the patient's health carrier and within 45 processing days of receiving the claim, the carrier shall offer to pay the professional a ‘reasonable reimbursement.’

If the provider declines the carrier's initial offer, the parties have 60 days from the initial offer to negotiate in good faith, and if the parties cannot reach agreement by the deadline, the dispute shall be resolved through a stipulated arbitration process. To initiate arbitration, either provider or carrier must submit a written notice to the department. Claims from similar circumstances may be bundled into one arbitration. The provider is prohibited from billing the patient for any difference in the billed charge and the reimbursement rate, and the patient is excluded from the arbitration process.

Arbitration costs shall be split equally between carriers and providers, and the arbitrator is charged with issuing a final decision that shall be binding. The health carrier and health care professional shall execute a nondisclosure agreement prior to the arbitration. The arbitrator shall determine a dollar amount due that is between 120 percent of the Medicare allowed amount and the 70th percentile of the usual and customary rate for the unanticipated OON care, as determined by benchmarks from independent nonprofit organizations not affiliated with insurance carriers or provider organizations.

The new law goes into effect January 1, 2019.