New Jersey bill aims to clarify out-of-network billing rules: 5 things to know

Two New Jersey lawmakers plan to introduce a new bill to address out-of-network billing, ROI-NJ reported.

Five things to know about the new bill:

1. The new bill — from New Jersey Democratic Sens. Joseph Lagana and Vin Gopal — aims to clarify and revisit parts of a law New Jersey Democratic Gov. Phil Murphy signed in May to combat unexpected out-of-network medical expenses.

2. The bill would use benchmarks for costs from national independent, nonprofit FAIR Health, to set minimum reimbursement for an out-of-network procedure, according to the report. This minimum reimbursement, set at the 85th percentile of charges from the FAIR Health database, would serve as a beginning point, and physicians and insurers could still debate the fee, per the original law.

3. The original law provides a path to resolve out-of-network billing disputes through "baseball-style" arbitration, where an arbitrator would select either the amount offered by the insurer or the fee sought by the provider as the reimbursement for care.

It stipulates that a claim needs to exceed $1,000 to go through arbitration, or the physician must accept the insurer's payment, which is based on what the insurer deems is fair market-value, according to the report. The new bill would eliminate the $1,000 minimum.

4. The new bill, which excludes self-funded health plans governed by federal ERISA law, also calls on the New Jersey Department of Insurance and Banking to better define "inadvertent" out-of-network care, according to the report.

5. Sens. Lagana and Gopal are expected to introduce the new bill this month.

Access the full ROI-NJ report here.


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How states are dealing with surprise billing

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