The original instrument was prepared by Cheryl Cooper. The following digest, which
does not constitute a part of the legislative instrument, was prepared by Brandi
Cannon.
DIGEST
SB 7 Engrossed 2020 First Extraordinary Session Talbot
Proposed law establishes a dispute resolution process by which a dispute for a bill for emergency
services or a surprise bill may be resolved. Authorizes the Department of Insurance the power to
grant certifications of independent dispute resolution entities to conduct the dispute resolution
process.
Proposed law excludes health care services, including emergency services, where physician fees are
subject to schedules or other monetary limitations under any other law, including, but not limited to,
workers' compensation, Medicaid, Medicare, or to health insurance plans that are subject to the
Employee Retirement Income Security Act of 1974 from the provisions of the proposed law.
Proposed law excludes from the provisions of the proposed law certain emergency services billed
under the American Medical Association Current Procedural Terminology codes 99281 through
99285, 99288, 99291 through 99292, 99217 through 99220, 99224 through 99226, and 99234
through 99236, when all the following criteria are met:
(1)The amount billed for any Current Procedural Terminology code is less than a threshold
amount that shall equal the amount from the prior year, beginning with $650, adjusted by the
average of the annual average inflation rates for the medical care commodities and medical
care services components of the consumer price index. In no event shall the threshold amount
exceed $1,200.
(2)The amount billed for the Current Procedural Terminology code does not exceed 120% of
the usual and customary cost for that Current Procedural Terminology code.
Proposed law provides that when a health insurance issuer receives a bill for emergency services or
a surprise bill from a nonparticipating physician, the health insurance issuer shall:
(1)Directly pay the nonparticipating physician the billed amount or attempt to negotiate
reimbursement with the nonparticipating physician. If the health insurance issuer's attempts
to negotiate reimbursement for the health care services provided by the nonparticipating
physician do not result in a resolution of the payment dispute, the health insurance issuer
shall pay the nonparticipating physician an amount the health insurance issuer determines is
reasonable for the health care services rendered, less the insured's copayment, coinsurance,
or deductible.
(2)Provide notice to the nonparticipating physician describing how to initiate the independent
dispute resolution process. (3)Ensure that the insured shall incur no greater out-of-pocket costs for the emergency services
than the insured would have incurred with a participating physician pursuant to the insured's
health insurance coverage.
Proposed law provides that the nonparticipating physician shall not bill the insured except for any
applicable copayment, coinsurance, or deductible.
Proposed law provides that in determining a reasonable fee for the services rendered, an independent
dispute resolution entity shall select either the health insurance issuer's payment or the
nonparticipating physician's fee. The independent dispute resolution entity shall determine which
amount to select based upon the conditions and factors set forth in proposed law. Requires the
determinations to be made within 30 days.
Proposed law provides that if the independent dispute resolution entity issues a determination in
favor of the nonparticipating physician, the health insurance issuer shall pay the nonparticipating
physician any additional amount owed within thirty days from the date of the determination.
Proposed law provides that if an insured who does not assign benefits receives a surprise bill, the
insured may submit an application to the department to request resolution of the dispute regarding
a fee or payment for a surprise bill by an independent dispute resolution entity. The independent
dispute resolution entity shall make a determination pursuant to the provisions of proposed law
within 30 days.
Proposed law provides that the determination of an independent dispute resolution entity shall be
binding on the health insurance issuer, physician and patient, and shall be admissible in any court
proceeding between the health insurance issuer, physician or patient, or in any administrative
proceeding between this state and the physician.
Proposed law provides that when an insured assigns benefits for a surprise bill in writing to a
nonparticipating physician that knows the insured is insured under health insurance coverage, the
nonparticipating physician shall not bill the insured except for any applicable copayment,
coinsurance, or deductible that would be owed if the insured utilized a participating physician.
Proposed law provides that in determining the appropriate amount to be paid for a health care
service, an independent dispute resolution entity shall consider all relevant factors, including:
(1)Whether there is a gross disparity between the fee charged by the physician for services
rendered as compared to:
(a)Fees paid to the involved physician for the same services rendered by the physician
to other patients in health insurance in which the physician is not participating.
(b)In the case of a dispute involving a health insurance issuer, fees paid by the health
insurance issuer to reimburse similarly qualified physicians for the same services in
the same region who are not participating with the health insurance issuer. (2)The level of training, education, and experience of the physician.
(3)The physician's usual charge for comparable services with regard to patients in health
insurance in which the physician is not participating.
(4)The circumstances and complexity of the particular case, including time and place of the
service.
(5)Individual patient characteristics.
(6)The usual and customary cost of the service, including historical data amounts.
(7)The 50th percentile of rates, including historical data, for the service or supply paid to
participating providers in the same or similar specialty and provided in the same
geographical area as reported in a benchmarking database maintained by a nonprofit
organization specified by the commissioner.
(8)The history of network contracting between the parties.
Proposed law provides that the nonprevailing party is required to pay the costs of the independent
dispute resolution entity. Further provides that when a good faith negotiation directed by the
independent dispute resolution entity results in a settlement between the health insurance issuer and
nonparticipating physician, the health insurance issuer and the nonparticipating physician shall
evenly divide and share the prorated cost for dispute resolution entity.
Proposed law is effective January 1, 2021.
(Adds R.S. 22:1885.1-1885.7)
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Insurance to the original bill
1. Changes references in proposed law from provider to physician.
2. Changes references in proposed law from health care plan to health insurance issuer.
3. Removes proposed law relative to assignment of benefits.
4. Specifies that a health insurance issuer must directly pay a nonparticipating
physician.
5. Prohibits a nonparticipating physician from billing the insured except for any
applicable copayment, coinsurance, or deductible. 6. Allows the independent dispute resolution entity to consider the 50th percentile of
rates, including the historical data of the rates, for the service paid to participating
providers in the same or similar specialty and provided in the same geographical area,
the history of network contracting between the parties, and the historical data for the
usual and customary cost of the service.
7. Makes proposed law effective Jan. 1, 2021.
8. Makes technical changes.