Sponsored by:
Senator VIN GOPAL
District 11 (Monmouth)
SYNOPSIS
Revises certain provisions of out-of-network health care services arbitration law.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance and health care providers and supplementing and amending P.L.2018, c.32.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. (New section) a. The Commissioner of Banking and Insurance shall establish a liaison within the department to assist carriers, providers, and covered persons with any issues that may arise concerning an arbitration conducted pursuant to P.L.2018, c.32 (C.26:2SS-1 et seq.). The liaison shall also communicate with any arbitrator contracted with by the department pursuant to section 10 of P.L.2018, c.32 (C.26:2SS-10).
b. The commissioner shall establish procedures for the liaison to receive information from, provide information to, and coordinate information among arbitrators, carriers, providers, and covered persons, concerning any arbitration or potential arbitration. Contact information for the liaison shall be prominently displayed on the department’s website. The liaison shall not provide legal counsel to any party.
2. Section 10 of P.L.2018, c.32 (C.26:2SS-10) is amended to read as follows:
10. a. If attempts to negotiate reimbursement for services provided by an out-of-network health care provider, pursuant to subsection c. of section 9 of [this act] P.L.2018, c.32 (C.26:2SS-9), do not result in a resolution of the payment dispute, and the difference between the carrier's and the provider's final offers is not less than $1,000, the carrier or out-of-network health care provider may initiate binding arbitration to determine payment for the services.
b. The binding arbitration shall adhere to the following requirements:
(1) The party requesting arbitration shall notify the other party that arbitration has been initiated and state its final offer before arbitration, which in the case of the carrier shall be the amount paid pursuant to subsection c. of section 9 of [this act] P.L.2018, c.32 (C.26:2SS-9). In response to this notice, the out-of-network provider shall inform the carrier of its final offer before the arbitration occurs;
(2) Arbitration shall be initiated by filing a request with the department;
(3) The department shall contract, through the request for proposal process, every three years, with one or more entities that have experience in health care pricing arbitration. The arbitrators shall be American Arbitration Association certified arbitrators. The department may initially utilize the entity engaged under the "Health Claims Authorization, Processing, and Payment Act," P.L.2005, c.352 (C.17B:30-48 et seq.), for arbitration under this act; however, after a period of one year from the effective date of this act, the selection of the arbitration entity shall be through the Request for Proposal process. Claims that are subject to arbitration pursuant to the provisions of this act, which previously would be subject to arbitration pursuant to the "Health Claims Authorization, Processing, and Payment Act," shall instead be subject to this act;
(4) The arbitration shall consist of a review of the written submissions by both parties, which shall include the final offer for the payment by the carrier for the out-of-network health care provider's fee made pursuant to subsection c. of section 9 of [this act] P.L.2018, c.32 (C.26:2SS-9) and the final offer by the out-of-network provider for the fee the provider will accept as payment from the carrier; [and]
(5) The arbitrator's decision shall be one of the two amounts submitted by the parties as their final offers and shall be binding on both parties. The decision of the arbitrator shall include written findings and shall be issued within 30 days after the request is filed with the department. The arbitrator's expenses and fees shall be split equally among the parties except in situations in which the arbitrator determines that the payment made by the carrier was not made in good faith, in which case the carrier shall be responsible for all of the arbitrator's expenses and fees. Each party shall be responsible for its own costs and fees, including legal fees if any; and
(6) All evidence submitted by the parties to the arbitration shall be available for examination by all parties to the arbitration. In considering any evidence submitted by the parties with regard to the cost of comparable services, the arbitrator shall give the greatest evidentiary weight to the cost of comparable services performed at or closest to the provider’s primary place of business.
c. (1) The amount awarded by the arbitrator that is in excess of any payment already made pursuant to subsection c. of section 9 of [this act] P.L.2018, c.32 (C.26:2SS-9) shall be paid within 20 days of the arbitrator's decision as provided in subsection b. of this section.
(2) The interest charges for overdue payments, pursuant to P.L.1999, c.154 (C.17B:30-23 et al.), shall not apply during the pendency of a decision under subsection b. of this section and any interest required to be paid a provider pursuant to P.L.1999, c.154 (C.17B:30-23 et al.) shall not accrue until after 20 days following an arbitrator's decision as provided in subsection b. of this section, but in no circumstances longer than 150 days from the date that the out-of-network provider billed the carrier for services rendered, unless both parties agree to a longer period of time.
d. This section shall apply only if the covered person complies with any applicable preauthorization or review requirements of the health benefits plan regarding the determination of medical necessity to access in-network inpatient or outpatient benefits.
e. This section shall not apply to a covered person who knowingly, voluntarily, and specifically selected an out-of-network provider for health care services.
f. In the event an entity providing or administering a self-funded health benefits plan elects to be subject to the provisions of section 9 of [this act] P.L.2018, c.32 (C.26:2SS-9), as provided in subsection d. of that section, the provisions of this section shall apply to a self-funded plan in the same manner as the provisions of this section apply to a carrier. If a self-funded plan does not elect to be subject to the provision of section 9 of [this act] P.L.2018, c.32 (C.26:2SS-9), a member of that plan may initiate binding arbitration as provided in section 11 of [this act] P.L.2018, c.32 (C.26:2SS-11).
g. The commissioner shall establish a process through which a party requesting arbitration may appeal a decision of an arbitrator to deny the request for arbitration. The appeal process shall allow for the review and reversal of any denial of a request for arbitration.
(cf: P.L.2018, c.32, s.10.)
3. This act shall take effect on the 90th day next following enactment.
STATEMENT
This bill revises certain provisions of the out-of-network health care services law concerning binding arbitration.
The bill requires the Commissioner of Banking and Insurance to establish a liaison within the Department of Banking and Insurance to assist carriers, providers, and covered persons with any issues that may arise concerning an arbitration conducted pursuant to the out-of-network health care services law. The liaison is also required to communicate with any arbitrator contracted with by the department pursuant to that law.
The bill requires the commissioner to establish procedures for the liaison to receive information from, provide information to, and coordinate information among arbitrators, carriers, providers, and covered persons, concerning any arbitration or potential arbitration. The bill provides that the liaison may not provide legal counsel to any party to an arbitration.
The bill provides that all evidence submitted by the parties to the arbitration is to be available for examination by all parties to the arbitration. In considering any evidence submitted by the parties with regard to the cost of comparable services, the bill requires the arbitrator to give the greatest evidentiary weight to the cost of comparable services performed at or closest to the provider’s primary place of business.
The bill requires the commissioner to establish a process through which a party requesting arbitration may appeal a decision of an arbitrator to deny the request for arbitration. The appeal process must allow for the review and reversal of any denial of a request for arbitration.