Balance Billing for Out-of-Network Providers


oppose5SB 629 – Health Care Services Billing Transparency

Primary Sponsors: Sen. Ralph Hise (R – Madison), Sen. Wesley Meredith (R – Cumberland)

Section 1 – Insurance and Managed Care Coverage Provisions

This bill states that if an insurer determines an in-network provider is able to meet the needs of the insured, and is reasonably available to the insured without unreasonable delay, the insurer will pay for any out-of-network services provided using a new benchmark outlined in this bill unless the provider and the insurer create another agreement.  This bill would not require an insurer to make any direct payment to a health care provider.

This bill states that a health care provider’s total payment for services provided outside of network or for emergency care services is reasonable if it is equal to the benchmark amount.

The benchmark would be calculated at the smallest amount among the following:

  • 100 percent of the current Medicare payment rate;
  • Health care provider’s charges;
  • Median concentrated rate for the same service in a similar area.

Provider’s that fail to comply would be deemed engaging in unfair and deceptive trade practice.

This bill defines a “clinical laboratory” as an entity where services are performed to provide materials for diagnosis, prevention or treatment.

This bill defines a “health care provider” as any health care services facility, or any person who is licensed, registered or certified under Chapter 90 of the General Statutes, or under the laws of another state to provide health services. Pharmacies are excluded in this definition.

This bill would define “health services facility” as a hospital, long-term care hospital, psychiatric facility, rehabilitation facility, nursing home, kidney disease treatment center, including freestanding hemodialysis units, intermediate care facility, home health agency office, chemical dependency treatment facility, diagnostic center, hospice office, hospice inpatient facility, hospice residential care facility, ambulatory surgical facility, urgent care facility, freestanding emergency facility, and clinical laboratory.

 

Health Care Provider Billing

A provider that does not participate in the provider network would be required to send a billing notice to the insured individual who is responsible for paying in-network cost sharing, but would have no legal obligation to pay the remaining balance when the benchmark applies.

This bill states that no provider would be able to bill insured individuals for services at a greater rate than the benchmark amount.

 

Penalties

This bill would subject providers that fail to comply with the requirements outlined in this bill to action under Chapter 75 of the General Statutes.

 
 

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