HLS 12RS-954 ORIGINAL
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are additions.
Regular Session, 2012
HOUSE BILL NO. 429
BY REPRESENTATIVE TALBOT
INSURANCE/HEALTH: Provides relative to balance billing by noncontracted facility-
based physicians for covered health care services rendered in an in-network health
care facility
AN ACT1
To enact R.S. 22:1882, relative to noncontracted facility-based physicians providing covered2
health care services rendered in an in-network health care facility; to provide for3
definitions; to provide with respect to reimbursement of such physicians by health4
insurance issuers; to provide for binding arbitration in certain circumstances; and to5
provide for related matters.6
Be it enacted by the Legislature of Louisiana:7
Section 1. R.S. 22:1882 is hereby enacted to read as follows: 8
ยง1882. Payment of claims for covered health care services provided by 9
noncontracted, facility-based physicians in in-network health care facilities10
A. For purposes of this Section:11
(1) "Base health care facility" means a facility or institution providing health12
care services, including but not limited to a hospital or other licensed inpatient13
center, ambulatory surgical or treatment center, skilled nursing facility, inpatient14
hospice facility, residential treatment center, diagnostic, laboratory, or imaging15
center, or rehabilitation or other therapeutic health setting that has entered into a16
contract or agreement with a facility-based physician. Pursuant to such contract or17
agreement, the facility-based physician agrees to provide required health care18 HLS 12RS-954 ORIGINAL
HB NO. 429
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services to those enrollees or insureds of the health insurance issuer presenting at1
such facility, within the scope of the physician's respective specialty.2
(2) "Noncontracted facility-based physician" means a physician licensed to3
practice medicine who is required by a base health facility to provide services in the4
base health care facility, including an anesthesiologist, hospitalist, intensivist,5
neonatologist, pathologist, or radiologist, that does not contract with a health6
insurance issuer.7
B.(1) If a facility-based physician files a claim with a health insurance issuer8
for covered health care services rendered to an enrollee or insured in an in-network9
health care facility, the health insurance issuer shall directly pay such claim by the10
noncontracted facility-based physician and shall reimburse him in an amount not less11
than the greatest of one of the following:12
(a) The amount negotiated with contracted facility-based physicians for13
covered health care services that are imposed with respect to the enrollee or insured,14
excluding any applicable in-network coinsurance, copayments, deductibles,15
noncovered services, or any other amounts identified by the health insurance issuer16
pursuant to plan or policy provisions as an amount for which the enrollee or insured17
is liable.18
(b) The amount of the covered health care services calculated using the same19
method a health insurance issuer uses to determine payments for out-of-network20
health care services, but using the in-network cost-sharing provisions instead of the21
out-of-network cost-sharing provisions.22
(c) The amount that would be paid under Medicare for the covered health23
care services, excluding any applicable in-network coinsurance, copayments,24
deductibles, noncovered services, or any other amounts identified by the health25
insurance issuer pursuant to plan or policy provisions as an amount for which the26
enrollee or insured is liable.27 HLS 12RS-954 ORIGINAL
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(2)(a) For capitated or other health insurance issuers that do not have a1
negotiated per-service amount for contracted facility-based physicians, Subparagraph2
(1)(a) of this Subsection shall not apply.3
(b) If a health insurance issuer has more than one negotiated amount for4
contracted facility-based physicians for a particular covered health care service, the5
amount in Subparagraph (1)(a) of this Subsection is the median of these negotiated6
amounts.7
(3) Payment of such claim by a health insurance issuer shall in no8
circumstance be made directly to a patient, enrollee, or insured.9
C.(1) Notwithstanding any other provisions of law to the contrary, in the case10
where a noncontracted facility-based physician fails to file a claim with a health11
insurance issuer for covered health care services rendered to an enrollee or insured12
in an in-network health care facility, the enrollee or insured shall be indemnified and13
held harmless by the health insurance issuer for such claim. The health insurance14
issuer shall be liable for reimbursement to the noncontracted facility-based physician15
for the covered health care services, except for any applicable in-network16
coinsurance, copayments, deductibles, noncovered services, or any other amounts17
identified by the health insurance issuer pursuant to plan or policy provisions as an18
amount for which the enrollee or insured is liable. A noncontracted facility-based19
physician shall be prohibited from billing an enrollee or insured for reimbursement20
for covered health care services, except for any applicable in-network coinsurance,21
copayments, deductibles, noncovered services, or any other amounts identified by22
the health insurance issuer pursuant to plan or policy provisions as an amount for23
which the enrollee or insured is liable.24
(2) If the attempts between the health insurance issuer and the noncontracted25
facility-based physician to negotiate or pay the noncontracted facility-based26
physician for covered health care services rendered to an enrollee or insured in an27
in-network health care facility do not result in resolution of the payment dispute28
within thirty days after receipt of a written explanation of benefits by the health29 HLS 12RS-954 ORIGINAL
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insurance issuer, then the health insurance issuer or the noncontracted facility-based1
physician may initiate binding arbitration to determine payment of the subject2
covered health care services. The party initiating arbitration shall notify the other3
party that arbitration has been initiated and state its final offer before arbitration4
occurs. In response to this notice, the party not initiating arbitration shall inform the5
party initiating arbitration of its final offer before arbitration occurs.6
D. The provisions of this Section shall not apply to limited benefit health7
plans, policies, or contracts.8
Section 2. This Act shall become effective upon signature by the governor or, if not9
signed by the governor, upon expiration of the time for bills to become law without signature10
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If11
vetoed by the governor and subsequently approved by the legislature, this Act shall become12
effective on the day following such approval.13
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Talbot HB No. 429
Abstract: Provides relative to balance billing by noncontracted facility-based physicians for
covered health care services rendered at an in-network health care facility by
providing with respect to reimbursement of such physicians by health insurance
issuers and providing for binding arbitration in certain circumstances.
Proposed law provides with respect to reimbursement of noncontracted facility-based
physicians of covered health care services as follows:
(1)Defines the terms "noncontracted facility-based physician" and "base health care
facility".
(2)Provides that if a facility-based physician files a claim with a health insurance issuer
for covered health care services rendered to an enrollee or insured in an in-network
health care facility, the health insurance issuer shall directly pay such claim by the
noncontracted facility-based physician and shall reimburse him in an amount not less
than the greatest of one of the following:
(a)The amount negotiated with contracted facility-based physicians for covered
health care services that are imposed with respect to the enrollee or insured,
excluding any applicable amounts identified by the health insurance issuer
pursuant to plan or policy provisions as an amount for which the enrollee or
insured is liable. HLS 12RS-954 ORIGINAL
HB NO. 429
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are additions.
(b)The amount of the covered health care services calculated using the same
method a health insurance issuer uses to determine payments for
out-of-network health care services, but using the in-network cost-sharing
provisions instead of the out-of-network cost-sharing provisions.
(c)The amount that would be paid under Medicare for the covered health care
services, excluding any applicable amounts for which the enrollee or insured
is liable.
(3)Further provides that for capitated or other health insurance issuers that do not have
a negotiated per-service amount for contracted facility-based physicians, (2)(a)
above shall not apply. Further provides that if a health insurance issuer has more
than one negotiated amount for contracted facility-based physicians for a particular
covered health care service, the amount in (2)(a) above shall be the median of these
negotiated amounts.
(4)Prohibits payment of any claim by a health insurance issuer directly to a patient,
enrollee, or insured.
(5)Additionally provides that in the case where a noncontracted facility-based physician
fails to file a claim with a health insurance issuer for covered health care services
rendered to an enrollee or insured in an in-network health care facility, the enrollee
or insured shall be indemnified and held harmless by the health insurance issuer for
such claim. Makes the health insurance issuer liable for reimbursement to the
noncontracted facility-based physician for the covered health care services, except
for any applicable amounts which the enrollee or insured is liable. Prohibits a
noncontracted facility-based physician from billing an enrollee or insured for
reimbursement for covered health care services, except for any applicable amounts
for which the enrollee or insured is liable.
(6)Also provides that if the attempts between the health insurance issuer and the
noncontracted facility-based physician to negotiate or pay him for covered health
care services rendered to an enrollee or insured in an in-network health care facility
do not result in resolution of the payment dispute within 30 days after receipt of a
written explanation of benefits by the health insurance issuer, then the health
insurance issuer or the noncontracted facility-based physician may initiate binding
arbitration to determine payment of the subject covered health care services.
Requires the party initiating arbitration to notify the other party that arbitration has
been initiated and state its final offer before arbitration occurs. In response to this
notice, requires the party not initiating arbitration to inform the other party initiating
arbitration of its final offer before arbitration occurs.
(7)Exempts limited benefit health insurance policies or contracts from its provisions.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Adds R.S. 22:1882)