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ARIZONA HOUSE OF REPRESENTATIVESFifty-fourth Legislature Second Regular Session |
Senate: HHS DPA/SE 8-0-0-0 | 3rd Read 29-0-1-0House: COM DPA 8-0-0-1 |
SB 1024: out-of-network claims; balance billing; disputes
Sponsor: Senator Brophy McGee, LD 28
Caucus & COW
Overview
Permits a self-funded or self-insured employee benefit plan to opt-in to the out-of-network claim dispute resolution process. Establishes a balance billing dispute resolution process for health care services organizations (HCSO).
History
Laws 2017, Chapter 190, established a process for an enrollee who has received a surprise out-of-network bill to seek a dispute resolution for the disputed amount. A surprise out-of-network bill is a bill for a health care service that was provided in a network facility by a health care provider that is not a contracted provider and that meets certain criteria to qualify as a surprise out-of-network bill. The dispute resolution process consists of an informal settlement teleconference and arbitration. The Department of Insurance (DOI) is required to develop a simple, fair, efficient and cost-effective arbitration procedure for surprise out-of-network bill disputes, as well as specify time frames, standards and other details for the arbitration proceeding. The Department must submit an annual report on the resolution of disputed surprise out-of-network bills (A.R.S. § 20-3118).
DOI reported receiving 91 dispute resolution inquiries during 2019. Of these, 53 cases had been resolved by December 31, 2019; 21 of these cases qualified for dispute resolution, and 32 did not qualify.
Balance billing, or a surprise medical bill, indicates a difference between a provider's charge and the amount allowed by an individual's health care plan. This occurs when a patient goes to an in-network hospital and is treated by an out-of-network doctor. (DOI)
A health care services organization is defined as any person that undertakes to conduct one or more health care plans. Unless the context otherwise requires, HCSO includes a provider sponsored HCSO. (A.R.S. § 20-1051)
Provisions
1.
Permits the Director of the DOI to use
monies from the Health Care Appeals Fund to perform the administrative function
of the out-of-network claim dispute resolution process. (Sec. 1)
2. Stipulates the out-of-network claim dispute resolution process applies to a self-funded or self-insured employee benefit plan that is otherwise preempted from state regulation by the Employee Retirement Income Security Act of 1974 (ERISA) if the entity that administers the plan enters into a written agreement with DOI to voluntarily comply with the dispute resolution requirements. (Sec. 4)
a) Specifies the Director must agree to allow the plan's enrollees to participate in the dispute resolution and arbitration proceedings. (Sec. 8)
b) Authorizes the Director to charge a fee for entering into a written agreement in an amount determined by the Director. (Sec. 8)
3. Applies out-of-network claim dispute resolution laws to certain health plans and state health and accidental coverage for state employees. (Sec. 4)
4. Specifies the applicability of dispute resolution laws does not negate or limit an HCSO's obligation to its members to ensure that covered health care services are delivered in accordance with each member's health care plan. (Sec. 4)
5. Asserts an HCSO enrollee is not a party to any payment dispute between the HCSO and a health care provider.
a) Requires the enrollee to be held harmless for certain disputed amounts. (Sec. 4)
6. Permits an HCSO that receives or a health care provider that seeks to collect a disputed balance bill to seek dispute resolution of the balance bill by filing a request for arbitration with DOI not later than one year after the date of service noted in the claim, if all of the following apply:
a) The enrollee has resolved any health care appeal that they may have had against the HCSO following the HCSO's initial adjudication of the claim;
i) Tolls the one-year period for requesting arbitration from the date that the enrollee files a health care appeal to the date of final resolution of the appeal;
b) The enrollee has not instituted a civil lawsuit or other legal action against the HCSO or the health care provider related to the same claim or the health care services provided; and
c) The amount of the balance bill for which the HCSO is responsible is at least $1,000. (Sec. 6, 7)
7. Requires the health care provider to participate in an inform settlement teleconference with an authorized HCSO representative if an HCSO requests dispute resolution of a balance bill.
a) Stipulates the teleconference is terminated if either party fails to attend, and the HCSO, within 14 days after the scheduled teleconference, may request that DOI set the case for arbitration. (Sec. 6)
8. Applies the requirements for conducting an arbitration proceeding of a surprise out-of-network bill dispute to balance bill disputes of an HCSO. (Sec. 7)
9. Declares an enrollee is not a party to any balance bill dispute between an HCSO and a health care provider.
a) Requires the HCSO and the health care provider to hold the enrollee harmless for the balance bill amount. (Sec. 7)
10. Requires the health care provider to refund any overpayment by an HCSO within 30 days after resolution of the claim. (Sec. 7)
11. Contains a legislative intent clause. (Sec. 9)
12. Defines balance bill, health care services organization and modifies the definition of contracted provider, health plan and network facility to include a health care services organization. (Sec. 3)
13. Makes technical changes. (Sec. 2, 5, 7)
Amendments
Committee on Commerce
1. Stipulates DOI must determine whether a surprise out-of-network bill or balance bill is subject to the process by evaluating whether the self-funded or self-insured employee benefit plan is substantially similar to a health plan issued by a health insurer or an HCSO.
2. Makes technical changes.
3.
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6. SB 1024
7. Initials PRB Page 0 Caucus & COW
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