New Jersey Assemblyman Gary Schaer (D-Passaic), Chair of the Financial Institutions and Insurance Committee, has re-introduced his HEALTH CARE DISCLOSURE AND TRANSPARENCY ACT (A-2751), and co-sponsored by Senator Joseph Vitale (S-848). This is the old out-of-network bill.
This bill was originally proposed in 2010 by Assemblyman Schaer (A-3378). The New Jersey Association of Ambulatory Surgery Centers opposed the bill, and vigorously engaged the Assemblyman over various sections of concern. Save for one big area of concern, the bill had reached the point where the industry could support it. The newly re-introduced bill does not address NJAASC's main concern, and adds a new section that could mean the bill would be opposed by other groups as well.
Of primary importance to the industry is Section 8, the "penalty section" so to speak. NJAASC has commented that a sole remedy provision needs to be added. This would mean that the penalties as prescribed in the bill itself would be the only ones applicable, that carriers could not also attempt a private cause of action-civil lawsuit (with treble damages).
A new section has been added wherein in-network facilities would be held accountable, to ensure that patients receiving treatment from a facility based provider who is out-of-network, would not incur higher costs than if that provider was in-network.
"This is obviously targeting the '-ologists' — anesthesia, radiology, pathology etc.," says Jeff Shanton, Chair of the Advocacy & Legislative Affairs Committee of NJAASC. "I don't know of any major carrier that gives an ASC an in-network contract without anesthesia also being in-network (and for some a global fee), so this is probably geared toward the hospitals. I am however concerned with the language that says both the out-of-network provider (-ologist) and the in-network facility shall ensure the patient not incur a higher cost than the patient would have incurred if the provider was in-network."
Centers and providers negotiate separately with the carriers; there is no set fee schedule (ala PIP or Medicare for instance) and no across the board template. Anesthesiologists are rarely owners in an ASC, so short of firing a group a center would have difficulty ensuring compliance.
This would also require an out-of-network provider to accept a fee that is pre-determined — or forced on them — with no ability to negotiate on their own.
"While preserving a viable out-of-network option remains an industry concern, the bill would be less impactful then two years ago, when originally introduced," says Mr. Shanton. "Even back in 2010, most centers were already doing many of the things proposed in this legislation, on their own, as part of their business practice. The landscape has changed dramatically from then to now, as the carriers have restructured insurance benefits to eliminate traditional out-of-network coverage for ASCs. Indeed, the entire out-of-network issue for ASCs is reduced, as many have chosen to go in-network."
This bill was originally proposed in 2010 by Assemblyman Schaer (A-3378). The New Jersey Association of Ambulatory Surgery Centers opposed the bill, and vigorously engaged the Assemblyman over various sections of concern. Save for one big area of concern, the bill had reached the point where the industry could support it. The newly re-introduced bill does not address NJAASC's main concern, and adds a new section that could mean the bill would be opposed by other groups as well.
Of primary importance to the industry is Section 8, the "penalty section" so to speak. NJAASC has commented that a sole remedy provision needs to be added. This would mean that the penalties as prescribed in the bill itself would be the only ones applicable, that carriers could not also attempt a private cause of action-civil lawsuit (with treble damages).
A new section has been added wherein in-network facilities would be held accountable, to ensure that patients receiving treatment from a facility based provider who is out-of-network, would not incur higher costs than if that provider was in-network.
"This is obviously targeting the '-ologists' — anesthesia, radiology, pathology etc.," says Jeff Shanton, Chair of the Advocacy & Legislative Affairs Committee of NJAASC. "I don't know of any major carrier that gives an ASC an in-network contract without anesthesia also being in-network (and for some a global fee), so this is probably geared toward the hospitals. I am however concerned with the language that says both the out-of-network provider (-ologist) and the in-network facility shall ensure the patient not incur a higher cost than the patient would have incurred if the provider was in-network."
Centers and providers negotiate separately with the carriers; there is no set fee schedule (ala PIP or Medicare for instance) and no across the board template. Anesthesiologists are rarely owners in an ASC, so short of firing a group a center would have difficulty ensuring compliance.
This would also require an out-of-network provider to accept a fee that is pre-determined — or forced on them — with no ability to negotiate on their own.
"While preserving a viable out-of-network option remains an industry concern, the bill would be less impactful then two years ago, when originally introduced," says Mr. Shanton. "Even back in 2010, most centers were already doing many of the things proposed in this legislation, on their own, as part of their business practice. The landscape has changed dramatically from then to now, as the carriers have restructured insurance benefits to eliminate traditional out-of-network coverage for ASCs. Indeed, the entire out-of-network issue for ASCs is reduced, as many have chosen to go in-network."
Related Articles on New Jersey ASCs:
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