A revised version of a New Jersey bill regulating the out-of-network insurance market in the state has been released, and the New Jersey Association of Ambulatory Surgery Centers said that while it is far from happy with the new bill, changes in it make this version more acceptable than previous bills, according to a statement from the NJAASC and Jeffrey Shanton, chair, Advocacy and Legislative Affairs Committee, NJAASC.
A previous version of the bill, introduced by N.J. Democratic Assemblyman Gary Schaer and replacing similar legislation Mr. Schaer introduced in October, would have required New Jersey OON ASCs and other providers to charge patients out-of-pocket costs in many cases. This bill failed to make it out of committee in November.
Mr. Schaer modified this version of the bill and it was recently released from committee.
"The NJAASC succeeded in keeping this bill in committee on the first try, in its amended — and for us unacceptable — form," says Mr. Shanton. "The present piece of legislation essentially reverts back to the language in the original draft of the bill. While we are far from happy, we can at least accept this version, knowing what could have been, and actually what might be.
"The Assemblyman did give into us on several points," he says. "Of particular importance is the provision that insurance carriers cannot throw doctors OON (in their professional practice) for taking patients to an OON center."
According to the NJAASC, here are six key provisions of the released bill:
1) OON providers would be required to make a "good faith and timely effort" to collect each patient's co-insurance, co-payment or deductible. If a provider makes three good faith and timely attempts to collect from a patient, such provider will be deemed to have made a "good faith and timely effort." The bill also contains a requirement that the provider retain all records relating to any "good faith and timely effort" to collect a patient's payment for seven years and make them available to DOBI for inspection upon request.
2) Providers may waive a patient's payment if the provider determines that the patient has a "medical or financial" hardship so long as (i) waivers are not granted "routinely or excessively" and (ii) providers must notify the carriers in the event that they grant such hardship waivers.
3) At the time of scheduling, OON doctors and facilities would be required to inform patients whether the healthcare services they seek are in-network or OON and the provider must: (i) explain to the patient his or her financial responsibility, including deductibles, co-payments and co-insurance; (ii) provide the patient with a description of any non-emergency services or elective procedures; and (iii) provide an estimation of the costs in the patient's primary language. Physicians in violation of this provision may be subject to licensure sanctions by the BME.
4) The recently enacted assignment of benefits legislation (AOB Law) would be modified by the proposed bill. The existing requirement under the AOB Law that forces a carrier to pay a provider directly (or pay the provider and patient jointly) was expanded to include self-funded health benefit plans. However, under the bill, OON providers may be excluded from the direct pay benefit of the AOB Law for a one year in the event a carrier or insurance entity determines that a provider engaged in a "pattern of violations" of the obligation to collect co-insurance, co-payments and/or deductibles, as set forth above, for a period of at least six months. Providers would have the right to appeal such determination to the Office of the Insurance Claims Ombudsman in DOBI in accordance with procedures outlined in the bill.
5) Carriers would be prohibited from terminating a provider from a managed care panel on the basis that the provider referred to an OON provider. Additionally, the bill would restrict carriers from making unilateral changes to participating provider agreements more than once a calendar year and requires them to provide 30 days advance written notice of any such changes to practitioners.
6) The bill also requires carriers and entities offering managed care plans or self-funded health benefits plans to maintain a website making available so called "quality rankings" of health care providers and other information deemed necessary by DOBI.
In order to become law, the bill must still be approved by the entire Assembly, go through the Senate committee structure and a full vote of the Senate, and then be signed by the New Jersey governor.
"There is considerable opposition to this bill in it's current form, from DOBI and the insurance carriers, who want much more severe language and criminal penalties for non-collection of patient responsibility," says Mr. Shanton. "If this bill gets passed in anything close to its present form, while not a victory, at least, it would not be a defeat for the industry."
Learn more about the New Jersey Association of Ambulatory Surgery Centers.
Read more about ambulatory surgery center news in New Jersey:
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