The original instrument and the following digest, which constitutes no part of the
legislative instrument, were prepared by Cheryl Cooper.
DIGEST
SB 316 Original 2016 Regular Session Donahue
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. 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 health care 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 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 August 1, 2016.
(Adds R.S. 22:1882)