Thursday, September 06, 2018

New Jersey balance billing protection law is strong on scheduled procedures

Earlier this week I raised a question whether New Jersey's new law protecting insured patients from balance billing requires patients in scheduled procedures to confirm in advance that not only the physician performing the procedure and the facility where it's performed are in network, but that all participating providers, such as anesthesiologists and radiologists, are also in-network. The question was triggered by language like this (Section 5b):
A health care professional who is a physician shall provide the covered person, to the extent the information is available, with the name, practice name, mailing address, and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology, or assistant surgeon services in connection with care to be provided in the physician’s office for the covered person or coordinated or referred by the physician for the covered person at the time of referral to, or coordination of, services with that provider. The physician shall provide instructions as to how to determine the health benefits plans in which the health care provider participates and recommend that the covered person should contact the covered person’s carrier for further consultation on costs associated with these services.
Other bill language, I noted, seems to indicate that the patient is not responsible for ascertaining that all personnel are in network. 

Maura Collinsgru, health care program director at New Jersey Citizen Action and a prime mover of the NJ for Health Care Coalition, tells me that the onus is not on the patient to make all those determinations:

The burden for ensuring in-network providers is on the facilities and providers.  We worked hard to ensure that disclosures can't put a consumer on the hook for something they have no control over. Consumers are responsible for ensuring the facility and primary provider they are scheduling with are "in-network".  Other treatment personnel they do not control (anesthesia, radiology, lab, assistant surgeons, etc.) they are not responsible for unless they specifically requested the OON provider.  
So that's good news. And the law is unequivocal that insured patients are not to be balance billed for procedures scheduled with an in-network provider at an in-network facility. The protection against balance billing in emergency procedures is comprehensive.

The protections going into force in New Jersey may be the strongest in the nation -- please see the prior post for a summary. Unique in the NJ law is the opt-in for self-funded health plans, which generally can't be touched by state balance billing regulations, and which insure well over half of people who are insured through their employer.  In New Jersey, the cards that self-funded plans provide to plan members will have to state whether the plan has opted in to the law's arbitration system to resolve billing disputes between plans and healthcare providers. I should think that public advocacy to encourage self-funded plans to opt in, and provide positive reinforcement when they do, might help create momentum and get most privately insured New Jerseyans protected from balance billing.

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