HLS 13RS-797 ORIGINAL
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are additions.
Regular Session, 2013
HOUSE BILL NO. 228
BY REPRESENTATIVES FANNIN AND CARMODY
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
INSURANCE/HEALTH: Provides relative to balance billing by and reimbursement of
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 providing2
covered health care services rendered in an in-network health care facility; to provide3
with respect to reimbursement of such physicians by health insurance issuers; to4
provide relative to balance billing by such physicians; and to provide for related5
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 by9
noncontracted facility-based physicians in in-network health care facilities;10
balance billing11
A. For purposes of this Section, "noncontracted facility-based physician"12
means a physician licensed to practice medicine who is required by a base health13
care facility to provide services in the base health care facility, including an14
anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, or radiologist,15
that does not contract with a health insurance issuer.16
B.(1) A health insurance issuer shall directly pay a claim by a noncontracted17
facility-based physician for covered health care services rendered to a patient,18 HLS 13RS-797 ORIGINAL
HB NO. 228
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enrollee, or insured in an in-network health care facility and shall reimburse him in1
an amount not less than the greatest of one of the following:2
(a)(i) The amount negotiated with contracted facility-based physicians for3
covered health care services that are imposed with respect to the enrollee or insured,4
excluding any applicable in-network coinsurance, in-network copayments,5
deductibles, or noncovered services.6
(ii) If there is more than one amount negotiated with contracted providers for7
covered health care services, the amount shall be the median of those amounts.8
(iii) If a health insurance issuer has more than one negotiated amount for9
contracted facility-based physicians for a particular covered health care service, this10
amount shall be the median of those negotiated amounts. In determining such11
median, the amount negotiated with each in-network provider shall be treated as a12
separate amount regardless if the same amount is paid to more than one provider.13
(iv) For capitated or other health insurance issuers that do not have a14
negotiated per-service amount for contracted facility-based physicians, this15
Subparagraph shall not apply.16
(b) The amount calculated for the covered health care services using the same17
method that the health insurance issuer generally uses to determine payments for18
out-of-network health care services, excluding any applicable in-network19
coinsurance, in-network copayments, deductibles, or noncovered services. The20
amount specified in this Paragraph shall be determined without regard for21
out-of-network cost sharing that generally applies under the policy or subscriber22
agreement with respect to out-of-network services.23
(c) The amount that would be paid under Medicare for the covered health24
care services, excluding any applicable in-network coinsurance, in-network25
copayments, deductibles, or noncovered services.26
(2) Payment of such claim by a health insurance issuer shall in no circumstance27
be made directly to a patient, enrollee, or insured.28 HLS 13RS-797 ORIGINAL
HB NO. 228
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C.(1) A health insurance issuer shall be liable for reimbursement to a1
noncontracted facility-based physician for covered health care services, except for any2
applicable in-network coinsurance, in-network copayments, deductibles, or noncovered3
services.4
(2) A patient, enrollee, or insured shall be indemnified and held harmless by a5
health insurance issuer for payment of a claim for covered health care services, except6
for any applicable in-network coinsurance, in-network copayment s, deductibles, or7
noncovered services.8
(3) A noncontracted facility-based physician shall be prohibited from billing a9
patient, enrollee, or insured for reimbursement for covered health care services, except10
for any applicable in-network coinsurance, in-network copayments, deductibles, or11
noncovered services.12
Section 2. This Act shall become effective upon signature by the governor or, if not13
signed by the governor, upon expiration of the time for bills to become law without signature14
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If15
vetoed by the governor and subsequently approved by the legislature, this Act shall become16
effective on the day following such approval.17
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. HLS 13RS-797 ORIGINAL
HB NO. 228
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are additions.
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)