SLS 14RS-627 ORIGINAL
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
Regular Session, 2014
SENATE BILL NO. 490
BY SENATOR HEITMEIER
HEALTH/ACC INSURANCE. 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. (8/1/14)
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 with3
respect to reimbursement of such physicians by health insurance issuers; to provide4
relative to balance billing by such physicians; and to provide for related matters.5
Be it enacted by the Legislature of Louisiana:6
Section 1. R.S. 22:1882 is hereby enacted to read as follows:7
ยง1882. Payment of claims for covered health care services provided by8
noncontracted facility-based physicians in in-network health care9
facilities; balance billing10
A. For purposes of this Section, "noncontracted facility-based physician"11
means a physician licensed to practice medicine who is required by a base12
health care facility to provide services in the base health care facility, including13
an anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, or14
radiologist, that does not contract with a health insurance issuer.15
B.(1) A health insurance issuer shall directly pay a claim by a16
noncontracted facility-based physician for covered health care services17 SB NO. 490
SLS 14RS-627 ORIGINAL
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
rendered to a patient, enrollee, or insured in an in-network health care facility1
and shall reimburse him in an amount not less than the greatest of one of the2
following:3
(a)(i) The amount negotiated with contracted facility-based physicians4
for covered health care services that are imposed with respect to the enrollee or5
insured, excluding any applicable in-network coinsurance, in-network6
copayments, deductibles, or noncovered services.7
(ii) If there is more than one amount negotiated with contracted8
providers for covered health care services, the amount shall be the median of9
those amounts.10
(iii) If a health insurance issuer has more than one negotiated amount for11
contracted facility-based physicians for a particular covered health care service,12
this amount shall be the median of those negotiated amounts. In determining13
such median, the amount negotiated with each in-network provider shall be14
treated as a separate amount regardless of whether the same amount is paid to15
more than one provider.16
(iv) This Subparagraph shall not apply to capitated or other health17
insurance issuers that do not have a negotiated per-service amount for18
contracted facility-based physicians.19
(b) The amount calculated for the covered health care services using the20
same method that the health insurance issuer generally uses to determine21
payments for out-of-network health care services, excluding any applicable22
in-network coinsurance, in-network copayments, deductibles, or noncovered23
services. The amount specified in this Paragraph shall be determined without24
regard for out-of-network cost sharing that generally applies under the policy25
or subscriber agreement with respect to out-of-network services.26
(c) The amount that would be paid under Medicare for the covered27
health care services, excluding any applicable in-network coinsurance,28
in-network copayments, deductibles, or noncovered services.29 SB NO. 490
SLS 14RS-627 ORIGINAL
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
(2) Payment of such claim by a health insurance issuer shall in no1
circumstance be made directly to a patient, enrollee, or insured.2
C.(1) A health insurance issuer shall be liable for reimbursement to a3
noncontracted facility-based physician for covered health care services, except4
for any applicable in-network coinsurance, in-network copayments, deductibles,5
or noncovered services.6
(2) A patient, enrollee, or insured shall be indemnified and held harmless7
by a health insurance issuer for payment of a claim for covered health care8
services, except for any applicable in-network coinsurance, in-network9
copayments, deductibles, or noncovered services.10
(3) A noncontracted facility-based physician shall be prohibited from11
billing a patient, enrollee, or insured for reimbursement for covered health care12
services, except for any applicable in-network coinsurance, in-network13
copayments, deductibles, or noncovered services.14
Section 2. This Act shall become effective upon signature by the governor or, if not15
signed by the governor, upon expiration of the time for bills to become law without signature16
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If17
vetoed by the governor and subsequently approved by the legislature, this Act shall become18
effective on the day following such approval.19
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Cheryl Horne.
DIGEST
Heitmeier (SB 490)
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-ba sed 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.
Specifies that 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 SB NO. 490
SLS 14RS-627 ORIGINAL
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
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 pay a claim directly 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 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 of whether 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)