HLS 18RS-1986 ENGROSSED
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)and R.S. 46:460.62, relative to the reimbursement
3 of contracted healthcare providers; to provide for payment to a new provider in a
4 contracted network of providers; to provide for recovery of certain amounts upon
5 denial of an 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 §1874. 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 * * *
8 Section 2. R.S. 46:460.62 is hereby amended and reenacted to read as follows:
9 §460.62. Interim credentialing requirements
10 A. Under certain circumstances and when the provisions of this Subsection
11 are met, a managed care organization contracting with a group of physicians
12 healthcare providers that bills a managed care organization utilizing a group
13 identification number, such as the group federal tax identification number or the
14 group National Provider Identifier as set forth in 45 CFR 162.402 et seq., shall pay
15 the contracted reimbursement rate of the physician provider group for covered health
16 care healthcare services rendered by a new physician provider to the group without
17 health care healthcare provider credentialing as described in this Subpart. This
18 provision shall apply in either of the following circumstances:
19 (1) When the new physician provider has already been credentialed by the
20 managed care organization, and the physician's provider's credentialing is still active
21 with the managed care organization.
22 (2) When the managed care organization has received the required
23 credentialing application that is correctly and fully completed and information,
24 including proof of active hospital privileges from the new physician provider, and
25 the managed care organization has not notified the physician provider group that
26 credentialing of the new physician provider has been denied.
27 B. A managed care organization shall comply with the provisions of
28 Subsection A of this Section no later than thirty days after receipt of a written request
29 from the physician provider group.
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HB NO. 775
1 C. Compliance by a managed care organization with the provisions of
2 Subsection A of this Section shall not be construed to mean that a physician provider
3 has been credentialed by the managed care organization, or the managed care
4 organization shall be required to list the physician provider in a directory of
5 contracted physicians healthcare providers.
6 D. If, after compliance with Subsection A of this Section, a managed care
7 organization completes the credentialing process on the new physician provider and
8 determines the physician provider does not meet the managed care organization's
9 credentialing requirements, the managed care organization may recover from the
10 physician provider or the physician provider group an amount equal to the difference
11 between appropriate payments for in-network benefits and out-of-network benefits,
12 provided that if the managed care organization has notified the applicant physician
13 provider of the adverse determination and provided that the prepaid entity has
14 initiated action regarding such the recovery within thirty days of the adverse
15 determination.
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 Engrossed 2018 Regular Session Davis
Abstract: Provides for payment 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 requires a health insurance issuer or managed care organization (MCO)
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
or MCO and the physician's credentialing is still active with the issuer or MCO.
(2)When the health insurance issuer or MCO has received the required credentialing
application and information, including proof of active hospital privileges, from the
new physician and the issuer or MCO 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.
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HB NO. 775
Present law requires a health insurance issuer or MCO to comply with present law no later
than 30 days after receipt of a written request from the physician group. Present law further
requires the request to the health insurance issuer to contain 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.
Present law provides that compliance by a health insurance issuer or MCO shall not be
construed to mean that a physician has been credentialed by an issuer or MCO or that the
issuer or MCO 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 or MCO, if the issurer or MCO completes
the credentialing process on a new physician and determines that the physician does not meet
the issuer's or MCO'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 or MCO 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.
Present 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 health insurance 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) and R.S. 46:460.62)
Summary of Amendments Adopted by House
The Committee Amendments Proposed by House Committee on Insurance to the
original bill:
1. Add provisions relative to provider reimbursement by managed care
organizations.
2. Make technical changes.
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