HLS 18RS-1986 ORIGINAL
2018 Regular Session
HOUSE BILL NO. 775
BY REPRESENTATIVE DAVIS
INSURANCE/HEALTH: Provides relative to the reimbursement of healthcare providers
1 AN ACT
2To amend and reenact R.S. 22:1874(A)(5), relative to the reimbursement of contracted
3 healthcare providers; to provide for payment to a new provider in a contracted
4 network of providers; to provide for recovery of certain amounts upon denial of an
5 application for credentialing; and to provide for related matters.
6Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 22:1874(A)(5) is hereby amended and reenacted to read as follows:
8 ยง1874. Billing by contracted health care healthcare providers
9 A.
10 * * *
11 (5)(a) Under certain circumstances and when the provisions of Subparagraph
12 (b) of this Paragraph are met, a health insurance issuer contracting with a group of
13 physicians healthcare providers that bills a health insurance issuer utilizing a group
14 identification number, such as the group federal tax identification number or the
15 group National Provider Identifier as set forth in 45 CFR162.402 et seq., shall pay
16 the contracted reimbursement rate of the physician provider group for covered health
17 care healthcare services rendered by a new physician provider to the group, without
18 health care healthcare provider credentialing as described in R.S. 22:1009. This
19 provision shall apply in either of the following circumstances:
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HB NO. 775
1 (i) When the new physician provider has already been credentialed by the
2 health insurance issuer and the physician provider's credentialing is still active with
3 the issuer.
4 (ii) When the health insurance issuer has received the required credentialing
5 application and information, including proof of active hospital privileges, from the
6 new physician provider and the issuer has not notified the physician provider group
7 that credentialing of the new physician provider has been denied.
8 (b) A health insurance issuer shall comply with the provisions of
9 Subparagraph (a) of this Paragraph no later than thirty days after receipt of a written
10 request from the physician provider group. The written request shall include a
11 statement that the physician provider group agrees that all contract provisions,
12 including the provision holding covered persons harmless for charges beyond
13 reimbursement by the issuer and deductible, coinsurance and copayments, apply to
14 the new physician provider. Such compliance shall apply to any claims for covered
15 services rendered by the new physician provider to covered persons on dates of
16 service no earlier than the date of the written request from the physician provider
17 group.
18 (c) Compliance by a health insurance issuer with the provisions of
19 Subparagraph (a) of this Paragraph shall not be construed to mean that a physician
20 provider has been credentialed by an issuer or that the issuer is required to list the
21 physician provider in a directory of contracted physicians healthcare providers.
22 (d) If, upon compliance with Subparagraph (a) of this Paragraph, a health
23 insurance issuer completes the credentialing process on the new physician provider
24 and determines that the physician provider does not meet the issuer's credentialing
25 requirements, the following actions shall be permitted:
26 (i) The health insurance issuer may recover from the physician provider or
27 the physician provider group an amount equal to the difference between appropriate
28 payments for in-network benefits and out-of-network benefits provided that if the
29 health insurance issuer has notified the applicant physician provider of the adverse
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HB NO. 775
1 determination and provided that the health insurance issuer has initiated action
2 regarding such the recovery within thirty days of the adverse determination.
3 (ii) The physician provider or the physician provider group may retain any
4 deductible, coinsurance, or copayment collected or in the process of being collected
5 as of the date of receipt of the issuer's determination, so long as the amount is not in
6 excess of the amount owed by the insured or enrollee for out-of-network services.
7 * * *
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)]
HB 775 Original 2018 Regular Session Davis
Abstract: Provides for payment by a health insurance issuer to a new provider in a
contracted network of healthcare providers and authorizes recovery of certain
amounts upon denial of an application for credentialing.
Present law provides for the billing by and reimbursement of healthcare providers contracted
with a health insurance issuer.
Proposed law retains present law.
Present law requires a health insurance issuer contracting with a group of physicians that
bills the health insurance issuer using a group identification number to pay the contracted
reimbursement rate of the physician group for covered healthcare services rendered by a new
physician to the group, without healthcare provider credentialing, in either of the following
circumstances:
(1)When the new physician has already been credentialed by the health insurance issuer
and the physician's credentialing is still active with the issuer.
(2)When the health insurance issuer has received the required credentialing application
and information, including proof of active hospital privileges, from the new
physician and the issuer has not notified the physician group that credentialing of the
new physician has been denied.
Proposed law retains present law but expands the applicability to healthcare providers.
Present law requires a health insurance issuer to comply with present law no later than 30
days after receipt of a written request from the physician group that includes a statement that
the physician group agrees that all contract provisions apply to the new physician for any
claims for covered services rendered by the new physician to covered persons on dates of
service no earlier than the date of the written request from the physician group.
Proposed law retains present law but expands the applicability to healthcare providers.
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HB NO. 775
Present law provides that compliance by a health insurance issuer shall not be construed to
mean that a physician has been credentialed by an issuer or that the issuer is required to list
the physician in a directory of contracted physicians.
Proposed law retains present law but expands the applicability to healthcare providers.
Present law authorizes a health insurance issuer, if the insurer completes the credentialing
process on a new physician and determines that the physician does not meet the issuer's
credentialing requirements, to recover from the physician or the physician group an amount
equal to the difference between appropriate payments for in-network benefits and
out-of-network benefits if the health insurance issuer has notified the applicant physician of
the adverse determination and initiated the recovery within 30 days of the adverse
determination.
Proposed law retains present law but expands the applicability to healthcare providers.
Proposed law authorizes the physician or the physician group to retain any deductible,
coinsurance, or copayment collected or in the process of being collected as of the date of
receipt of the issuer's determination, so long as the amount is not in excess of the amount
owed by the insured or enrollee for out-of-network services.
Proposed law retains present law but expands the applicability to healthcare providers.
(Amends R.S. 22:1874(A)(5))
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CODING: Words in struck through type are deletions from existing law; words underscored
are additions.