HLS 19RS-51 ORIGINAL
2019 Regular Session
HOUSE BILL NO. 371
BY REPRESENTATIVE TALBOT
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
INSURANCE/HEALTH: Establishes an independent dispute resolution process for certain
out-of-network health benefit claims
1 AN ACT
2To enact Chapter 21 of Title 22 of the Louisiana Revised Statutes of 1950, to be comprised
3 of R.S. 22:2481 through 2496, relative to independent dispute resolution for out-of-
4 network health benefit claims; to define key terms; to provide for applicability and
5 scope; to require the commissioner of insurance to establish an independent dispute
6 resolution process for out-of-network claims in certain circumstances; to require
7 notice of fee and billing information to patients; to provide for dispute resolution
8 conducted by the division of administrative law; to provide for the payment of costs;
9 and to provide for related matters.
10Be it enacted by the Legislature of Louisiana:
11 Section 1. Chapter 21 of Title 22 of the Louisiana Revised Statutes of 1950,
12comprised of R.S. 22:2481 through 2496, is hereby enacted to read as follows:
13 CHAPTER 21. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
14 PART I. GENERAL PROVISIONS
15 §2481. Definitions
16 As used in this Chapter, the following definitions apply:
17 (1) "Administrator" means an administrator, including a third-party
18 administrator, for a health benefit plan providing coverage pursuant to the provisions
19 of this Title.
20 (2) "Commissioner" means the commissioner of insurance.
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1 (3) "Department" means the Department of Insurance.
2 (4) "Emergency care" means healthcare items and services furnished or
3 required to evaluate and treat an emergency medical condition.
4 (5) "Emergency care provider" means a physician, healthcare practitioner,
5 facility, or other healthcare provider who provides and bills an enrollee,
6 administrator, or health benefit plan for emergency care.
7 (6) "Emergency medical condition" means a medical condition manifesting
8 itself by symptoms of sufficient severity, including severe pain, such that a prudent
9 layperson, who possesses an average knowledge of health and medicine, could
10 reasonably expect that the absence of immediate medical attention would result in
11 serious impairment to bodily functions, serious dysfunction of a bodily organ or part,
12 or would place the person's health or, with respect to a pregnant woman, the health
13 of the woman or her unborn child, in serious jeopardy.
14 (7) "Enrollee" means an individual who is eligible to receive benefits
15 through a preferred provider benefit plan or a health benefit plan.
16 (8) "Facility" means an institution providing healthcare services or a
17 healthcare setting, including but not limited to hospitals and other licensed inpatient
18 centers, ambulatory surgical or treatment centers, skilled nursing centers, diagnostic,
19 laboratory and imaging centers, and rehabilitation and other therapeutic health
20 settings.
21 (9) "Facility-based provider" means a physician, healthcare practitioner, or
22 other healthcare provider who provides health care or medical services to patients
23 of a facility.
24 (10) "Healthcare practitioner" means an individual who is licensed to
25 provide healthcare services.
26 §2482. Applicability
27 This Chapter shall apply to both of the following:
28 (1) A preferred provider benefit plan offered by an insurer.
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1 (2) An administrator of a health benefit plan, other than a health maintenance
2 organization plan.
3 §2483. Reform
4 This Chapter shall not be construed to prohibit either of the following:
5 (1) An insurer offering a preferred provider benefit plan or administrator
6 from, at any time, offering a reformed claim settlement.
7 (2) A facility-based provider or emergency care provider from, at any time,
8 offering a reformed charge for health care or medical services or supplies.
9 PART II. INDEPENDENT DISPUTE RESOLUTION
10 §2491. Independent dispute resolution
11 A. The commissioner shall establish an independent dispute resolution
12 process by which a dispute for an out-of-network health benefit claim shall be
13 referred to the division of administrative law for resolution.
14 B. The division of administrative law shall use licensed healthcare providers
15 in active practice in the same or similar specialty as the facility-based provider or
16 emergency care provider whose fee for healthcare services is subject to the dispute
17 resolution process of this Chapter. To the extent practicable, the healthcare provider
18 shall be licensed in this state.
19 §2492. Independent dispute resolution; threshhold; exception
20 A. An enrollee may request independent dispute resolution pursuant to this
21 Chapter for an out-of-network health benefit claim if both of the following apply:
22 (1) The amount for which the enrollee is responsible to a facility-based
23 provider or emergency care provider, after copayments, deductibles, and
24 coinsurance, including the amount unpaid by the administrator or insurer, is greater
25 than five hundred dollars.
26 (2) The health benefit claim is for either of the following:
27 (a) Emergency care.
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1 (b) A healthcare or medical service or supply provided by a facility-based
2 provider in a facility that is a preferred provider or that has a contract with the
3 administrator.
4 B. Except as provided by Subsections C and D of this Section, if an enrollee
5 requests independent dispute resolution pursuant to this Chapter, the facility-based
6 provider or emergency care provider, or the provider's representative, and the insurer
7 or the administrator, as appropriate, shall participate in the independent dispute
8 resolution.
9 C. If requested by the enrollee, except in the case of an emergency, a
10 facility-based provider shall, before providing a healthcare or medical service or
11 supply, provide a complete disclosure to an enrollee that does all of the following:
12 (1) Explains that the facility-based provider does not have a contract with the
13 enrollee's health benefit plan.
14 (2) Discloses projected amounts for which the enrollee may be responsible.
15 (3) Discloses the circumstances in which the enrollee would be responsible
16 for those amounts.
17 D. A facility-based provider who makes a disclosure pursuant to Subsection
18 C of this Section and obtains the enrollee's written acknowledgment of that
19 disclosure shall not be required to participate in independent dispute resolution for
20 a billed charge pursuant to this Chapter if the amount billed is less than or equal to
21 the maximum amount projected in the disclosure.
22 §2493. Notice and information provided to enrollee
23 A. A bill sent to an enrollee by a facility-based provider or emergency care
24 provider or an explanation of benefits sent to an enrollee by an insurer or
25 administrator for an out-of-network health benefit claim eligible for independent
26 dispute resolution pursuant to this Chapter shall contain, in not less than ten-point
27 boldface type, a conspicuous, plain-language explanation of the independent dispute
28 resolution process available pursuant to this Chapter, including information on how
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1 to request dispute resolution and a statement that is substantially similar to the
2 following:
3 "You may be able to reduce some of your out-of-pocket costs for an
4 out-of-network medical or healthcare claim that is eligible for independent dispute
5 resolution by contacting the Department of Insurance at (website) and (phone
6 number)."
7 B. If an enrollee contacts an insurer, administrator, facility-based provider,
8 or emergency care provider about a bill that may be eligible for independent dispute
9 resolution pursuant to this Chapter, the insurer, administrator, facility-based
10 provider, or emergency care provider shall do both of the following:
11 (1) Inform the enrollee about independent dispute resolution pursuant to this
12 Chapter.
13 (2) Provide the enrollee with the Department of Insurance's toll-free
14 telephone number and internet website address.
15 §2494. Request for independent dispute resolution; preliminary procedures
16 A.(1) An enrollee requesting independent dispute resolution shall make the
17 request to the department on a form prescribed by the commissioner and shall
18 include all of the following:
19 (a) The name of the enrollee requesting independent dispute resolution.
20 (b) A brief description of the claim to be resolved.
21 (c) Contact information, including a telephone number, for the requesting
22 enrollee and the enrollee's counsel, if the enrollee retains counsel.
23 (d) The name of the facility-based provider or emergency care provider and
24 name of the insurer or administrator.
25 (e) Any other information the commissioner may require by rule.
26 (2) Within five days of receipt of a request for independent dispute
27 resolution, the department shall provide the division of administrative law with a
28 copy of the request for independent dispute resolution and shall notify the
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1 facility-based provider or emergency care provider and insurer or administrator of
2 the request.
3 (3) An enrollee may withdraw the request for independent dispute resolution
4 at any time before a determination is made by the division of administrative law
5 judge.
6 B. On receipt of notice from the department that an enrollee has made a
7 request for independent dispute resolution that meets the requirements of this
8 Chapter, the facility-based provider or emergency care provider shall not pursue any
9 collection effort against the enrollee who has requested independent dispute
10 resolution for amounts other than copayments, deductibles, and coinsurance before
11 the earlier of either of the following:
12 (1) The date the independent dispute resolution is completed.
13 (2) The date the request for independent dispute resolution is withdrawn.
14 C.(1) On receipt of notice from the department that an enrollee has made a
15 request for independent dispute resolution that meets the requirements of this
16 Chapter, the insurer or administrator shall immediately pay the facility-based
17 provider or emergency care provider any additional amounts required to provide for
18 a reimbursement amount not less than one hundred percent of the Medicare rate for
19 the healthcare services rendered by the facility-based provider or emergency care
20 provider, except for the enrollee's copayment, coinsurance, or deductible, if any, and
21 shall ensure that the enrollee incurs no greater out-of-pocket costs for the healthcare
22 services than the enrollee would have incurred with an in-network provider.
23 (2) Payment by an insurer pursuant to this Subsection shall in no
24 circumstance be made directly to a patient, enrollee, or insured.
25 §2495. Determination of a reasonable fee; criteria; good faith negotiation
26 A. In determining a reasonable fee for the services rendered, the division of
27 administrative law judge shall select either the insurer's or administrator's payment
28 or the out-of-network facility-based provider's or emergency care provider's fee. The
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1 independent dispute resolution entity shall determine which amount to select based
2 upon the conditions and factors provided for in Subsection B of this Section.
3 B. In determining the appropriate amount to pay for a healthcare service, the
4 division of administrative law judge shall consider all relevant factors, including but
5 not limited to all of the following:
6 (1) Whether there is a gross disparity between the fee charged by the
7 facility-based provider or emergency care provider, for services rendered as
8 compared to either of the following:
9 (a) Fees paid to the facility-based provider or emergency care provider for
10 the same services rendered by the provider to other patients in health benefit plans
11 in which the facility-based provider or emergency care provider is not participating.
12 (b) Fees paid by the insurer to reimburse similarly qualified facility-based
13 providers or emergency care providers for the same services in the same region who
14 are not participating with the health benefit plan.
15 (2) The level of training, education, and experience of the facility-based
16 provider or emergency care provider.
17 (3) The facility-based provider's or emergency care provider's usual charge
18 for comparable services with regard to patients in health benefit plans in which the
19 facility-based provider or emergency care provider is not participating.
20 (4) The circumstances and complexity of the particular case, including time
21 and place of the service.
22 (5) Individual patient characteristics.
23 (6) The usual and customary cost of the service.
24 C.(1) If the division of administrative law judge determines, based on the
25 insurer's or administrator's payment and the out-of-network facility-based provider's
26 or emergency care provider's fee, that a settlement between the insurer or
27 administrator and the facility-based provider or emergency care provider is
28 reasonably likely, or that both the insurer's or administrator's payment and the
29 out-of-network facility-based provider's or emergency care provider's fee represent
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1 unreasonable extremes, then the administrative law judge may direct both parties to
2 attempt a good faith negotiation for settlement.
3 (2) The insurer or administrator and the out-of-network facility-based
4 provider or emergency care provider may be granted up to ten business days for this
5 negotiation, which shall run concurrently with the period for dispute resolution
6 prescribed by the commissioner.
7 D. The determination of the administrative law judge shall be binding on the
8 insurer or administrator, facility-based provider or emergency care provider, and
9 enrollee, and shall be admissible in any court proceeding between the insurer or
10 administrator, facility-based provider or emergency care provider, or enrollee, or in
11 any administrative proceeding between this state and the facility-based provider or
12 emergency care provider.
13 §2496. Payment of costs
14 A. The commissioner shall promulgate a fee schedule for payment of the
15 costs of the independent dispute resolution process established pursuant to this
16 Chapter.
17 B.(1) For disputes involving an enrollee, when the division of administrative
18 law judge determines the health benefit plan's payment is reasonable, payment for
19 the dispute resolution process shall be the responsibility of the out-of-network
20 facility-based provider or emergency care provider.
21 (2) When the division of administrative law judge determines the
22 out-of-network the facility-based provider's or emergency care provider's fee is
23 reasonable, payment for the dispute resolution process shall be the responsibility of
24 the health benefit plan.
25 (3) When a good faith negotiation directed by the division of administrative
26 law judge pursuant to R.S. 22:2496 results in a settlement between the health benefit
27 plan and out-of-network facility-based provider or emergency care provider, the
28 health benefit plan and the out-of-network provider shall evenly divide and share the
29 prorated cost for the dispute resolution process.
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HB NO. 371
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 371 Original 2019 Regular Session Talbot
Abstract: Establishes an independent dispute resolution process for out-of-network health
benefit claims in certain circumstances.
Proposed law defines "administrator", "commissioner", "department", "emergency care",
"emergency care provider", "emergency medical condition", "enrollee", "facility",
"facility-based provider", and "healthcare practitioner".
Proposed law applies to a preferred provider benefit plan offered by an insurer or an
administrator of a health benefit plan, other than a health maintenance organization plan.
Proposed law requires the commissioner of insurance to establish an independent dispute
resolution process by which a dispute for an out-of-network health benefit claim shall be
referred to the division of administrative law for resolution if both of the following apply:
(1)The amount for which the enrollee is responsible to a facility-based provider or
emergency care provider, after copayments, deductibles, and coinsurance, including
the amount unpaid by the administrator or insurer, is greater than $500.
(2)The health benefit claim is for either emergency care or a healthcare or medical
service or supply provided by a facility-based provider in a facility that is a preferred
provider or that has a contract with the administrator.
Proposed law exempts a facility-based provider who makes a disclosure of projected out-of-
network costs to an enrollee prior to service and obtains the enrollee's written
acknowledgment of that disclosure from participating in independent dispute resolution for
a billed charge if the amount billed is less than or equal to the maximum amount projected
in the disclosure.
Proposed law requires notice of the available independent dispute resolution process to be
provided to an enrollee by a healthcare provider or an insurer or administrator for an
out-of-network health benefit claim eligible for independent dispute resolution.
Proposed law requires the commissioner of insurance, within five days of receipt of a request
for independent dispute resolution, to provide the division of administrative law with a copy
of the request and to notify the facility-based provider or emergency care provider and
insurer or administrator of the request.
Proposed law prohibits the facility-based provider or emergency care provider, on receipt
of notice from the department that an enrollee has made a request for independent dispute
resolution, from pursuing any collection effort against the enrollee who has requested
independent dispute resolution for amounts other than copayments, deductibles, and
coinsurance before the earlier of either the date the independent dispute resolution is
completed or the date the request for independent dispute resolution is withdrawn.
Proposed law requires the insurer or administrator to immediately pay the facility-based
provider or emergency care provider any additional amounts required to provide for a
reimbursement amount not less than 100% of the Medicare rate for the healthcare services
rendered by the facility-based provider or emergency care provider, except for the enrollee's
copayment, coinsurance, or deductible, if any, and to ensure that the enrollee incurs no
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greater out-of-pocket costs for the healthcare services than the enrollee would have incurred
with an in-network provider.
Proposed law sets forth the criteria for determining a reasonable fee for the services rendered
and requires the division of administrative law judge to select either the insurer's or
administrator's payment or the out-of-network facility-based provider's or emergency care
provider's fee.
Proposed law authorizes the administrative law judge, if a settlement between the insurer or
administrator and the facility-based provider or emergency care provider is reasonably
likely, or both the insurer's or administrator's payment and the out-of-network facility-based
provider's or emergency care provider's fee represent unreasonable extremes, to direct both
parties to attempt a good faith negotiation for settlement.
Proposed law provides for the payment of the costs of the independent dispute resolution.
(Adds R.S. 22:2481-2496)
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