Out-of-network ASCs and other providers will be required to charge patients out-of-pocket costs in many cases under a new bill introduced by New Jersey Democratic Assemblyman Gary Schaer.
The bill, replacing similar legislation Mr. Schaer introduced a month ago, raises concerns among ASCs and other providers who face insurers' efforts to stifle their out-of-network status.
Donald Cinotti, MD, an ophthalmologist who works in an ASC and is president of the Medical Society of New Jersey, says he is unhappy with provisions requiring physicians to estimate how much their bill will be and to determine if a patient has a financial hardship before waiving the out-of-pocket.
Jeffrey Shanton, director of business management at Journal Square Surgical Center in Jersey City, N.J., says he is unhappy with a provision that would bar providers from waiving out-of-pocket payments that "a reasonable person" would recognize as an "inducement" to obtain services. "What is 'a reasonable person'?" he asks. "That is too open-ended."
Here are some key provisions of the proposed law, a copy of which was provided by Mr. Shanton.
1. A provider out-of-network services may not waive out-of-pocket payments from the patient "in any manner or form which a reasonable person would recognize as an inducement to obtain services or supplies from a physician or healthcare facility."
2. A provider may waive out-of-pocket if the patient has "a medical or financial hardship," if "such waivers are not granted routinely or excessively" or if the provider has "a recognized historical or charitable mission," under the terms of an advisory opinion by the HHS Office of the Inspector General.
3. The provider must notify the carrier whenever a member's out-of-pocket have been waived.
4. The provider must charge the patient "at a rate equivalent to the average in-network rate as determined by the Department of Banking and Insurance."
5. If the facility is out-of-network, personnel must make sure patients are not billed any more than they would have been billed in an in-network facility.
6. When scheduling an appointment, providers must tell the patient whether they are in-network or out-of-network, provide an estimate of the bill, and give patients "a notice to contact their insurance carrier for further consultation on the costs of the procedure."
Read more coverage on out-of-network payments in New Jersey:
- New Out-of-Network Bill in New Jersey Would Further Regulate Such Relationships
- New Jersey ASCs Face New Tactics by Payors to Eliminate OON Services
- New Jersey Regulators Approve Penalties for PIP Patients Using OON Centers