Lawmakers unveil newest out-of-network, Health Price Index bills

It's back and bigger, with a double dose of transparency: the out-of-network bill and a new Health Price Index bill are on the table for the state Legislature.

The Health Price Index was originally a part of the much-anticipated out-of-network bill, but will now exist as a standalone piece of legislation, state lawmakers said Tuesday.

The final and newer drafts of both the HPI and the OON bills were released by Assemblyman Craig Coughlin (D-Woodbridge), Sen. Joseph Vitale (D-Woodbridge), Assemblyman Gary Schaer (D-Passaic) and Assemblyman Troy Singleton (D-Mount Laurel).

“These bills reflect the invaluable input we received and the many discussions we had with multiple stakeholder groups including, but not limited to consumers, health care facilities, health care providers, health insurers, businesses and industry.  We are incredibly grateful to the representatives of these stakeholder groups for giving so much of their time and expertise toward resolving this important issue impacting consumers throughout New Jersey,” Coughlin said in an emailed statement.

The Health Price Index will collect data from various sources, including medical claims, pharmacy claims, behavioral health claims, provider files and covered person eligibility files containing records associated with each of the claims files reported, in order to provide a peek into the costs of health care services around the state. This information will also include claims filed through Medicaid and Medicare.

The HPI was the first legislative step towards a more transparent health care system in the state, and helps to set a standard for costs of out-of-network services. It will be overseen by the Department of Banking and Insurance, which will select a storage company for the data as well as an organization to manage the HPI.

The idea of a more transparent health care system has been the position of New Jersey Health Care Quality Institute’s head, Linda Schwimmer.

 “Although we know that greater transparency is crucial to improving quality and reducing costs, there are always compromises that need to happen to get things done. Protecting people from surprise bills is essential, and if this compromise protects people it's worth making in the short term,” Schwimmer said.

Details of the out-of-network bill indicate a robust and administration-heavy approach to ensuring all the I’s are dotted and T’s are crossed.

Each out-of-network facility, or facility that uses out-of-network service providers, will have to make it explicitly clear to patients which services are and are not covered under their insurance. This applies to all non-emergency procedures and services, and will involve continuous updating on the part of the provider.

If, for example, a provider is in-network, but at some point before the patient has the procedure becomes out-of-network, the patient must be notified at least 30 days prior to the procedure. The bill allows for verbal notification prior to the procedure if the change takes place in less than 30 days.

In addition, the websites of all health care facilities will have to list the insurance providers that they accept, as well as provide written copies to patients.

While the original goal was to stop hefty surprise out-of-network costs for New Jersey residents, the bill intends to make health care providers play an active role in the billing process and ensure patients are receiving as much information as possible to have greater control over their health care costs.

Though emergency care is already covered by state law, and treated as in-network, a line in the out-of-network bill states that emergency care will not be billed “in excess of the lowest deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the covered person’s health benefits plan.”

And in the case of an “inadvertent” surprise bill, with all these pre-emptive procedures in place, arbitration is an option.

“If the carrier and the professional cannot agree on a reimbursement rate for the services provided pursuant to subsection a. of this section within 45 days after the carrier is billed for the service, the carrier, professional or covered person, as applicable, may initiate binding arbitration,” according to the latest draft of the bill.

The legislators hope to pass the bills by the end of the lame duck session.

Original article