N.J. Democratic Assemblyman Gary Schaer, chairman of the Assembly's Financial Institutions and Insurance Committee, has introduced legislation to further regulate the out-of-network relationships in the state, according to Mark Manigan, JD, an attorney with the Health Law Practice Group at Brach Eichler.
Chairman Schaer's committee is expected to take up the bill as early as Oct. 18.
"It's going to be a very hotly contested bill," says Mr. Manigan. "We'll be in the middle of the scrum defending the provider community."
Here are the six key provisions of the bill, according to Mr. Manigan.
1. OON providers would be required to make three "good faith and timely attempts" to collect each patient's co-insurance, co-payment or deductible. They must retain all records relating to these efforts for seven years and make them available to state inspectors upon request.
2. Providers may waive a patient's payment if they determine the patient has a medical or financial hardship, as long as waivers are not granted "routinely or excessively" and providers notify carriers when waivers are granted.
3. At the time of scheduling, OON doctors and facilities must inform patients whether the healthcare services they seek are in-network or OON. The provider must explain to the patient his or her financial responsibility, including deductibles, co-payments and co-insurance as well as provide a description of any non-emergency services or elective procedures and give the patient a cost estimate in the patient's primary language. Physicians violating this provision may be subject to state licensure sanctions.
4. The new bill would modify recently enacted state "assignment of benefits" legislation. Previous legislation that forces carriers to pay a provider directly or pay the provider and patient jointly was expanded to include self-funded health benefit plans. Under the new bill, however, OON providers may be excluded from the direct-pay benefit of the law for a one year if the carrier determines the provider engaged in a "pattern of violations" of the obligation to collect out-of-pocket payments from the patient for a period of at least six months. Providers could appeal this determination to the N.J. Office of the Insurance Claims Ombudsman.
5. Carriers would be prohibited from terminating a provider from a managed care panel solely because the provider referred patients to an OON provider. The bill would also restrict carriers from making unilateral changes in participating provider agreements more than once a calendar year and requires them to give practitioners 30 days written notice of any such changes.
6. Carriers offering managed care plans or self-funded health benefits plans must maintain a website displaying quality rankings of healthcare providers and other information deemed necessary by the state.