• SURPRISE!!! The NJ Out-of-Network Consumer Protection, Transparency, Cost Containment, and Accountability Act Goes Forward and Stalls
  • January 19, 2016 | Author: Grace D. Mack
  • Law Firm: Wilentz, Goldman & Spitzer P.A. - Woodbridge Office
  • On November 17, 2015, New Jersey lawmakers forged ahead with the controversial legislation that addresses, among other things, “surprise” medical bills from out of network providers. According to its sponsors, the purpose of the Out-of-Network Consumer Protection, Transparency, Cost Containment, and Accountability Act (A-4444/S-20) is to ensure that patients are informed about out-of-pocket costs before they schedule a service. The latest version of the bill removed a major provision that would have included use of the Healthcare Price Index (HPI), which would have allowed consumers and researchers access to average prices for healthcare services delivered inside patients’ insurance networks. Along with removing the HPI (now contained in a separate bill), legislators made several other significant changes to the bill.

    First, self-funded health plans would have the option to participate in the new system set up by the bill. Second, the Act provides for binding arbitration to resolve disputes between doctors and hospitals and insurers and patients. However, billing disputes could receive a peer review by independent medical experts before going to arbitration and the process would now be limited to reimbursements of at least $1,000. Third, patients will not be required to pay more for emergency services than the least-expensive service in their insurance network. Although notice would still have to be given before scheduling an out of network service, the bill dropped the requirement that providers inform patients of potential out-of-pocket costs 30 days before delivering a service.

    The bill also provides that it is a violation for an out of network health care provider to waive all or part of a patient’s deductible, copayment or coinsurance as an inducement to seek covered services from the provider.

    The Medical Society of New Jersey continued its criticism of the bill fearing the concentrated power of insurers will leave physicians with less power to negotiate fair rates.

    More recently, however, on December 11, 2015, the Legislation stalled when the sponsor pulled it from a committee agenda after learning it did not have enough votes to pass. The bill’s sponsor, Sen. Joseph Vitale asked the Senate Commerce Committee to pull the bill from consideration because of "additional questions by members, and the gross misrepresentation of the facts by greed-driven special interests."

    We will continue to monitor the status of the “surprise bill” legislation.