SLS 16RS-558 ORIGINAL
2016 Regular Session
SENATE BILL NO. 316
BY SENATOR DONAHUE
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. (8/1/16)
1 AN ACT
2 To enact R.S. 22:1882, relative to noncontracted facility-based physicians providing covered
3 health care services rendered in an in-network health care facility; to provide with
4 respect to reimbursement of such physicians by health insurance issuers; to provide
5 relative to balance billing by such physicians; and to provide for related 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 by
9 noncontracted facility-based physicians in in-network health care
10 facilities; balance billing
11 A. For purposes of this Section, "noncontracted facility-based physician"
12 means a physician licensed to practice medicine who is required by a base
13 health care facility to provide services in the base health care facility, including
14 an anesthesiologist, hospitalist, intensivist, neonatologist, pathologist, or
15 radiologist, that does not contract with a health insurance issuer.
16 B.(1) A health insurance issuer shall directly pay a claim by a
17 noncontracted facility-based physician for covered health care services
Page 1 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 316
SLS 16RS-558 ORIGINAL
1 rendered to a patient, enrollee, or insured in an in-network health care facility
2 and shall reimburse him in an amount not less than the greatest of one of the
3 following:
4 (a)(i) The amount negotiated with contracted facility-based physicians
5 for covered health care services that are imposed with respect to the enrollee or
6 insured, excluding any applicable in-network coinsurance, in-network
7 copayments, deductibles, or noncovered services.
8 (ii) If there is more than one amount negotiated with contracted
9 providers for covered health care services, the amount shall be the median of
10 those amounts.
11 (iii) If a health insurance issuer has more than one negotiated amount for
12 contracted facility-based physicians for a particular covered health care service,
13 this amount shall be the median of those negotiated amounts. In determining
14 such median, the amount negotiated with each in-network provider shall be
15 treated as a separate amount regardless of whether the same amount is paid to
16 more than one provider.
17 (iv) This Subparagraph shall not apply to capitated or other health
18 insurance issuers that do not have a negotiated per-service amount for
19 contracted facility-based physicians.
20 (b) The amount calculated for the covered health care services using the
21 same method that the health insurance issuer generally uses to determine
22 payments for out-of-network health care services, excluding any applicable
23 in-network coinsurance, in-network copayments, deductibles, or noncovered
24 services. The amount specified in this Paragraph shall be determined without
25 regard for out-of-network cost sharing that generally applies under the policy
26 or subscriber agreement with respect to out-of-network services.
27 (c) The amount that would be paid under Medicare for the covered
28 health care services, excluding any applicable in-network coinsurance,
29 in-network copayments, deductibles, or noncovered services.
Page 2 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 316
SLS 16RS-558 ORIGINAL
1 (2) Payment of such claim by a health insurance issuer shall in no
2 circumstance be made directly to a patient, enrollee, or insured.
3 C.(1) A health insurance issuer shall be liable for reimbursement to a
4 noncontracted facility-based physician for covered health care services, except
5 for any applicable in-network coinsurance, in-network copayments, deductibles,
6 or noncovered services.
7 (2) A patient, enrollee, or insured shall be indemnified and held harmless
8 by a health insurance issuer for payment of a claim for covered health care
9 services, except for any applicable in-network coinsurance, in-network
10 copayments, deductibles, or noncovered services.
11 (3) A noncontracted facility-based physician shall be prohibited from
12 billing a patient, enrollee, or insured for reimbursement for covered health care
13 services, except for any applicable in-network coinsurance, in-network
14 copayments, deductibles, or noncovered services.
15 Section 2. This Act shall become effective upon signature by the governor or, if not
16 signed by the governor, upon expiration of the time for bills to become lawwithout signature
17 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
18 vetoed by the governor and subsequently approved by the legislature, this Act shall become
19 effective on the day following such approval.
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
Page 3 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 316
SLS 16RS-558 ORIGINAL
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)
Page 4 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.