Delaware’s governor signs legislation into law that modifies physician assistant (PA) supervision requirements. The Tennessee legislature will discuss a bill to modify reimbursement for out-of-network providers.
Scope of Practice
Delaware Gov. John Carney signed House Bill (HB) 33 into law. The law changes the practice agreement between a physician and a PA from a supervising to a collaborating agreement. PAs are permitted to order therapeutic orders and procedures.
Out-Of-Network Billing
In Tennessee, Senate Bill 1/House Bill 1 will be heard before the Senate Commerce and Labor Committee. Both bills would require the State Insurance Commissioner to establish an independent dispute resolution process to resolve disputes about charges for out-of-network emergency services. The Commissioner would promulgate rules establishing standards for the independent dispute resolution process, including a process for certifying and selecting independent dispute resolution entities.
In determining the appropriate amount to pay for a healthcare service, an independent dispute resolution entity would not consider:
- Any benchmarking database that includes Medicare or Medicaid reimbursement rates.
- Medicare or Medicaid reimbursement rates.
An out-of-network facility-based physician, healthcare facility, or health carrier may submit a dispute regarding a fee or payment for emergency services for review to an independent dispute resolution entity. The independent dispute resolution entity would decide on a reasonable fee for the services rendered within 30 days of receipt of the dispute for review.
When determining a reasonable fee for the services rendered, the independent dispute resolution entity would select either the health carrier payment or the out-of-network facility-based physician's fee.
If an independent dispute resolution entity determines, based on the health carrier's payment and the out-of-network facility-based physician's fee, that a settlement between the health carrier and out-of-network facility-based physician is reasonably likely, or that both the health carrier's payment and the out-of-network facility-based physician's fee represent unreasonable extremes, then the independent dispute resolution entity may direct both parties to attempt a good faith negotiation for settlement. In that case, the health carrier and out-of-network physician may be granted up to 10 business days for negotiation, which runs concurrently with the 30-day period for dispute resolution. An out-of-network facility-based physician may request, and the independent dispute resolution entity may permit, that claims of a physician involving the same health carrier be aggregated and submitted for simultaneous review by an independent dispute resolution entity when the specific reason for nonpayment of the claims aggregated involve a dispute regarding a common substantive question of fact or law.
If a balance bill is received by an enrollee for elective services who does not assign benefits, or who is uninsured, then the enrollee may submit a dispute regarding the balance bill for review to an independent dispute resolution entity that shall determine a reasonable fee for the services rendered.
For disputes involving an enrollee:
- When the independent dispute resolution entity determines the health carrier's payment is reasonable, the out-of-network facility-based physician or healthcare facility would pay for arbitration; and if the entity determines the out-of-network facility-based physician's or healthcare facility's fee is reasonable, the carrier would pay for arbitration.
- When a good-faith negotiation directed by the independent dispute resolution entity results in a settlement between the carrier and the out-of-network facility-based physician or healthcare facility, the carrier and the out-of-network facility-based physician or healthcare facility shall evenly divide and share the prorated cost of the dispute resolution.
To stay abreast of state legislative developments relevant to radiology, view our policy map.