by Matthew Albright, Chief Legislative Affairs Officer, Zelis
2018 Balance Billing Laws Restrict Providers
Four states adopted balance billing laws, continuing a trend we have seen over the last few years in which states are prohibiting balance billing in the case of out-of-network (OON) emergency services and/or non-emergency services provided by an OON provider in an in-network facility. Unlike previous state laws, the common theme in laws passed this year is the requirement that the provider accept or negotiate appropriate reimbursement from the payer, in contrast to previous state laws that put the onus on the payer to make the provider whole.
The most prominent example is the balance billing law passed in New Jersey (NJ A2039) which prohibits the provider from balance billing the member for both OON emergency and “inadvertent out-of-network services.” In both cases, the provider is prohibited from balance billing the member and the payer and provider can negotiate. Ultimately, the payer can pay the provider what it thinks is appropriate. If the provider disagrees with the reimbursement by more than $999, then the provider can initiate arbitration.
When appropriate, Zelis uses these state balance billing laws to protect members from balance billing and to arrive at appropriate reimbursement rates when we negotiate RBP reimbursement and payment integrity appeals.
States Slow Down on Adopting Provider Directory Laws
Currently, 29 States plus Washington, D.C. have requirements regarding provider directories. No other States have enacted provider directory laws in 2018; however, certain State legislatures have amended their existing laws.
For example, Louisiana passed a relatively minor directory law (LA HB 875) that requires carriers to conduct “ongoing review[s]” of their directories. With the addition of Louisiana, there are now 10 states that require periodic reviews or audits.
A number of health plans use Zelis’ Provider360 to support reviews and audits of their directory data. The Provider360 data quality reporting and monitoring platform provides a continuous review process that is not found in other review methods in the market.
Laws with minimal requirements with regard to credentialing and provider agreements were passed in Arizona (AZ HB 2322), Connecticut (CT HB5383), Louisiana (LA HB 775) and Tennessee (TN HB 498, TN SB 437). Finally, although not directly related to directory data, New Jersey buried a requirement for carriers to conduct annual third-party audits of their networks’ adequacy in NJ A2039.
Electronic Payments Pushed in Workers Compensation
Only one state law was passed regarding virtual cards and ACH healthcare payments to providers. Georgia HB 818 permits virtual card payments but requires alternative payment methods and provides that healthcare providers may choose the payment method for reimbursement.
In the workers’ compensation sector, there was more activity. Louisiana SB 85 and New Hampshire SB 84 allow workers’ compensation payments to be sent via EFT ACH if elected by the employee. Regulations finalized in Tennessee now require both providers and payers to use ERA (X12 835) and EFT (or other electronic payment if agreed upon) for workers’ compensation medical payments. Regulations proposed in Virginia in June require both providers and payers to use ERA (X12 835) and EFT (or other electronic payment if agreed upon) for workers’ compensation medical payments, effective – pending finalization of the proposed rule – January 1, 2109.
CMS Gears Up for Administrative Transaction Audits on Health Plan
The initial pilot seems to be wrapping up, so we expect the Centers for Medicare & Medicaid Services (CMS) to launch its audit on administrative transactions soon. For the audit, CMS will test health plans’ transaction files, including electronic remittance advice files (X12 835), and ask health plans to attest they are compliant with standards and operating rules for EFT. Zelis tested its X12 835 files in CMS’ in-house testing engine in the spring. Find some tips on how to prepare for the audit in this brochure.