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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. 497
BY SENATOR HEITMEIER
HEALTH CARE. Provides for the payment of health care services. (8/1/14)
AN ACT1
To amend and reenact R.S. 40:2203.1, relative to prohibition of certain practices by2
preferred provider organizations; and to provide for related matters.3
Be it enacted by the Legislature of Louisiana:4
Section 1. R.S. 40:2203.1 is hereby amended and reenacted to read as follows:5
ยง2203.1. Prohibition of certain practices by preferred provider organizations6
A. Except as otherwise provided in this Subsection, the requirements of this7
Section shall apply to all any preferred provider organization agreements that are8
applicable to medical services rendered in this state and to group purchasers as9
defined in this Part. The provisions of this Section shall not apply to a group10
purchaser when providing health benefits through its own network or direct provider11
agreements or to such agreements of a group purchaser.12
B. A preferred provider organization's alternative rates of payment shall not13
be enforceable or binding upon any provider unless such organization is clearly14
identified on the benefit card issued by the group purchaser or other entity accessing15
a the group purchaser's contractual agreement or agreements and presented to the16
participating provider when medical care is provided. When more than one preferred17 SB NO. 497
SLS 14RS-447 ORIGINAL
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
provider organization is shown on the benefit card of a group purchaser or other1
entity, the applicable contractual agreement that shall be binding on a provider shall2
be determined as follows:3
(1) The first preferred provider organization domiciled in this state, listed on4
the benefit card, beginning on the front of the card, reading from left to right, line by5
line, from top to bottom, that is applicable to a specific provider on the date medical6
care is rendered, shall establish the contractual agreement for payment that shall7
apply.8
(2) If there is no preferred provider organization domiciled in this state listed9
on the benefit card, the first preferred provider organization domiciled outside this10
state listed on the benefit card, following the same process outlined in Paragraph (1)11
of this Subsection shall establish the contractual agreement for any payment that12
shall apply.13
(3) The side of the benefit card that prominently identifies the name of the14
insurer, or plan sponsor and beneficiary shall be deemed to be the front side of the15
card.16
(4) When no preferred provider organization is listed, the plan sponsor or17
sponsors or insurer identified by the card shall be deemed to be the group purchaser18
for purposes of this Section.19
(5) When no benefit card is issued or utilized by a group purchaser or other20
entity, written notification shall be required of any each entity accessing an existing21
group purchaser's contractual agreement or agreements at least thirty days prior to22
accessing services through a participating provider under such agreement or23
agreements.24
C. A preferred provider organization agreement shall not be applied or used25
on a retroactive basis unless all providers of medical services that are affected by the26
application of alternative rates of payment receive written notification from the entity27
that seeks such an arrangement and agree in writing to be reimbursed at the28
alternative rates rate of payment.29 SB NO. 497
SLS 14RS-447 ORIGINAL
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
D. In no instance shall any provider be bound by the terms of a preferred1
provider organization agreement that is in violation of any provisions of this Part.2
E. Any claim submitted by a provider for services provided to a person3
identified by the provider and a group purchaser as eligible for alternative rates of4
payment in a preferred provider agreement shall be subject to the all standards for5
claims submission and timely payment according to the provisions of Subpart B of6
Part II of Chapter 6 of Title 22 of the Louisiana Revised Statutes of 1950.7
F. A group purchaser establishing a preferred provider organization shall be8
prohibited from charging a credentialing fee or any other type of monetary fee, when9
no access to a group purchaser is otherwise provided. Any provider who participates10
in a preferred provider organization may be charged a reasonable fee either on a11
periodic basis or based on the tangible benefits received from continued participation12
in a preferred provider organization. Such fees may be based on actual utilization of13
alternative rates of payment by group purchasers or other authorized entities or other14
reasonable basis other than membership.15
G. Failure to comply with the provisions of Subsection A, B, C, D, or F of16
this Section shall subject a group purchaser to damages payable to the provider of17
double the fair market value of the medical services provided, but in no event less18
than the greater of fifty dollars per day of noncompliance or two thousand dollars,19
together with attorney fees to be determined by the court. A provider may shall20
institute this action in any court of competent jurisdiction.21
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Cheryl Horne.
DIGEST
Heitmeier (SB 497)
Proposed law makes technical changes.
Effective August 1, 2014.
(Amends R.S. 40:2203.1.)