May 13, 2020

States Legislatures Address High-Priority Imaging and COVID-19 Issues

Lawmakers in two states will hear proposed legislation relevant to out-of-network billing. Louisiana’s Senate chamber has advanced a bill requiring insurance coverage for COVID-19 testing. In Michigan, the Senate has advanced a bill echoing an executive order that has suspended physician supervision requirements temporarily.

Out-of-Network Billing

In Ohio, the House Finance Committee will hold a hearing on HB 388. The bill would allow carriers to reimburse an out-of-network provider for unanticipated out-of-network care when services are provided to a covered person at an in-network facility and when the services would be covered when provided by an individual in-network provider.

Carriers would reimburse individual out-of-networker provider and out-of-network facilities for emergency services provided to an enrollee at an out-of-network emergency facility:

Unless the individual provider wishes to negotiate reimbursement, the reimbursement required to be paid to an individual provider would be the greatest of the following amounts:

  • The amount negotiated with individual in-network providers for the service in question, excluding any in-network cost sharing imposed under the health benefit plan. If there is more than one amount negotiated with individual in-network providers for the service, the relevant amount shall be the median of those amounts, excluding any in-network cost sharing imposed under the health benefit plan. In determining the median amount, the amount negotiated with each individual in-network provider shall be treated as a separate amount even if the same amount is paid to more than one provider.
  • The amount for the service calculated using the same method the health benefit plan generally uses to determine payments for out-of-network healthcare services, such as the usual, customary and reasonable amount, excluding any in-network cost sharing imposed under the health benefit plan. This amount shall be determined without reduction for cost sharing that generally applies under the health benefit plan with respect to out-of-network healthcare services.

For emergency services, unless the out-of-network emergency facility wishes to negotiate reimbursement, the reimbursement required to be paid to an out-of-network emergency facility would be the greatest of the following amounts:

  • The amount negotiated with in-network emergency facilities for the service in question, excluding any in-network cost sharing imposed under the health benefit plan. If there is more than one amount negotiated with in-network emergency facilities for the service, the relevant amount shall be the median of those amounts, excluding any in-network cost sharing imposed under the health benefit plan. In determining the median amount, the amount negotiated with each in-network emergency facility shall be treated as a separate amount even if the same amount is paid to more than one provider.
  • The amount for the service calculated using the same method the health benefit plan generally uses to determine payments for out-of-network healthcare services, such as the usual, customary and reasonable amount, excluding any in-network cost sharing imposed under the health benefit plan. This amount shall be determined without reduction for cost sharing that generally applies under the health benefit plan with respect to out-of-network healthcare services.

In the event of a dispute, providers or emergency facilities may request arbitration. If arbitration does not commence within 90 days of the request, the health plan issuer would reimburse the individual provider or emergency facility the amount of the provider's or facility's final offer.

An arbitrator shall only award either party's final offer and the non-prevailing party would pay 70% of the arbitrator's fees and the costs of arbitration, and the prevailing party would pay thirty percent.

Louisiana

In Louisiana, the House Insurance Committee will hold a hearing on HB 283. The bill would prohibit out-of-network billing and would define reimbursement for out-of-network facility-based providers.

If there are no in-network providers at the facility, the amount billed or collected by the facility-based physician would be equal to or less than the median amount paid by the carrier to in-network providers for the same or similar services provided in the same parish as the base healthcare facility.

The facility-based physician would be prohibited from billing, attempting to collect from, or collecting from an enrollee other than the coinsurance, copayments, deductibles or other amounts identified by the carrier on an explanation of benefits as an amount for which the enrollee is liable. The physician would also be prohibited from billing for services above the in-network rate for similar services at the facility.

COVID-19 Testing Coverage

In Louisiana, SB 426 is scheduled for its third reading in the Senate. The bill would prohibit carriers from denying coverage for COVID-19 diagnostic tests, antibody tests, and antiviral drugs. The bill would also mandate carriers to cover the aforementioned tests and drugs.

Scope of Practice

In Michigan, SB 880 was referred to the Senate Health Policy and Human Services Committee. The bill is in response to Gov. Gretchen Whitmer’s Executive Order No. 2020-61, which temporarily suspends physician supervision for physician assistants and advanced practice registered nurses. The measure would suspend physician supervision during the state of emergency due to the COVID-19 pandemic.