May 28, 2020

States Advance Surprise Billing and Scope of Practice Legislation

State legislatures in Louisiana and Ohio spent recent weeks working out details for regulating out-of-network billing. Vermont lawmakers will consider legislation that would relax supervision requirements for physician assistants.

Out-of-Network Billing

In Louisiana, HB 283 is scheduled for a third reading on the House floor. 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 fees from an enrollee, other than 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.

In Ohio, HB 388 passed the House chamber and was referred to the Senate Rules and Reference Committee. 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 providers 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.

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 per cent.

Scope of Practice

In Vermont, SB 128 is scheduled for a hearing before the House Health Care Committee. 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.