October 10, 2019

State Legislatures Discuss Bills Addressing Hot Button Imaging Issues

Legislative committees in Massachusetts and Ohio considered bills in early October that address scope of practice, breast tomosynthesis and out-of-network billing in their states.

Scope of Practice

In Massachusetts, the Joint Committee on Health Care Financing heard testimony on HB 1868 and its Senate companion bill SB 716. The bill expands the scope of practice of nurse anesthetists to include the ordering and interpreting of tests and the ordering and evaluation of treatment and therapeutics.

Breast Tomosynthesis

In Massachusetts, a hearing before the Joint Committee on Financial Services weighed the merits of HB 1025 and its Senate companion bill SB 616. The bills amend the state law to provide coverage for breast tomosynthesis in the following conditions:

  • For a baseline mammogram, for women between 35 and 40
  • For an annual mammogram, for women 40 or older
  • For a mammography examination for women under 40 with family history of breast cancer or other breast cancer risk factors
  • For ultrasound evaluation, MRI or additional mammography testing, of an entire breast or breasts if the screening mammogram, screening ultrasound or MRI shows any abnormality where additional examination is deemed medically necessary by the radiologist or the patient’s health care provider
  • For screening breast ultrasound or screening breast MRIs if the patient has additional risk factors for breast cancer including, but not limited to, family history, prior personal history of breast cancer, positive genetic testing, heterogeneously or extremely dense breast tissue, or other indications as determined by the patient’s health care provider
  • For a diagnostic mammogram, diagnostic breast ultrasound evaluation or breast MRI scan if the patient has a history of breast cancer, or
  • For MRI in place of, or in addition to, a mammogram when a mammogram is unable to detect cancers due to insufficient breast tissue as ordered by a patient’s physician.

Out-of-Network Billing

In Ohio, the Senate Insurance and Financial Institutions Committee heard testimony on SB 198. The bill would prohibit providers from billing health care plan enrollees the difference between the reimbursement from the plan’s issuer and provider’s charge for the services for unanticipated out-of-network care.

If the claim is not subject to arbitration, the issuer would reimburse the provider the lesser of the provider's charge and the eightieth percentile of all provider charges in the same or similar specialty for the health care service provided in the same geographical area as reported in a benchmarking database maintained by a nonprofit organization specified by the state superintendent of insurance.

Other than for unanticipated medical procedures, for health care services covered under a health benefit plan and provided by an out-of-network provider, the provider would be prohibited from billing the enrollee the difference between the issuer’s out-of-network reimbursement and the provider’s charge for the services, unless all of the following conditions are met:

  • The provider informs the enrollee that the provider is not in their provider network
  • The provider provides the enrollee an estimate of the cost of the health care services which would include a disclaimer that the enrollee is not required to obtain the services from that provider or location
  • The enrollee affirmatively consents to receive the health care services

In the event of arbitration, an arbitrator would award either the provider's final offer or the issuer's final offer, plus the arbitrator's fees, which shall be paid by the non-prevailing party.

In Massachusetts, SB 2364 was referred to the Joint Committee on Health Care Financing. The bill would mandate that for nonemergency health care services performed by an out-of-network health care provider without the enrollee’s knowledge, the issuer would pay the provider the non-contracted commercial rate for nonemergency services for each service. The enrollee would not be charged, except for applicable copayment, coinsurance or deductible.

The payment rate for emergency and nonemergency services would not be more than the eightieth percentile of all allowed charges for a particular health care service performed by a health care provider in the same or similar specialty and in the same geographical area, as reported in a benchmarking database by a nonprofit organization specified by the division of insurance.