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)]
Fannin HB No. 228
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.
Present law, the Health Care Consumer Billing and Disclosure Act, defines a "base health care
facility" as a facility or institution providing health care services that has entered into a contract,
agreement, or other arrangement with a facility-based physician. Specifies that pursuant to such
arrangement, the facility-based physician agrees to provide required health care services to those
patients, enrollees, or insureds of the health insurance issuer presenting at such facility, within
the scope of the physician's respective specialty. Also defines a "health insurance issuer" as any
entity that offers health insurance coverage through a policy or certificate of insurance subject to
state law that regulates the business of insurance. For purposes of proposed law, a "health
insurance issuer" shall include a health maintenance organization, certain nonfederal government
plans, and the office of group benefits.
Proposed law additionally defines a "noncontracted facility-based physician" as a physician who
is required by a base healthcare facility to provide services in the base health care facility,
including an anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, or radiologist,
that does not contract with a health insurance issuer.
Proposed law provides with respect to reimbursement of noncontracted facility-based physicians
for covered health care services rendered in an in-network health care facility, as follows:
(1)Requires a health insurance issuer to directly pay a claim by a noncontracted
facility-based physician for covered health care services rendered to a patient, enrollee, or
insured in an in-network health care facility and to 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 in-network coinsurance, in-network copayments,
deductibles, or noncovered services. Further provides that if there is more than
one amount negotiated with contracted providers for covered health care services,
the amount shall be the median of those amounts. Additionally 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 shall be the median of those negotiated amounts. Provides that, in determining
such median, the amount negotiated with each in-network provider shall be
treated as a separate amount regardless if the same amount is paid to more than
one provider. Also specifies that for capitated or other health insurance issuers
that do not have a negotiated per-service amount for contracted facility-based
physicians, these provisions shall not apply.
(b)The amount calculated for the covered health care services using the same method
that the health insurance issuer generally uses to determine payments for
out-of-network health care services, excluding any applicable in-network
coinsurance, in-network copayments, deductibles, or noncovered services.
Specifies that this amount shall be determined without regard for out-of-network
cost sharing that generally applies under the policy or subscriber agreement with
respect to out-of-network services.
(c)The amount that would be paid under Medicare for the covered health care
services, excluding any applicable in-network coinsurance, in-network
copayments, deductibles, or noncovered services.
(2)Provides that payment of such a claim by a health insurance issuer shall in no
circumstance be made directly to a patient, enrollee, or insured.
(3)Provides that a health insurance issuer shall be liable for reimbursement to a
noncontracted facility-based physician for covered health care services, except for any
applicable in-network coinsurance, in-network copayments, deductibles, or noncovered
services. Further provides that a patient, enrollee, or insured shall be indemnified and
held harmless by a health insurance issuer for payment of a claim for covered health care
services, except for such amounts. Prohibits a noncontracted facility-based physician
from billing a patient, enrollee, or insured for reimbursement for covered health care
services, except for such amounts.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Adds R.S. 22:1882)