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New NJ Bill to Address Confusion Over Surprise Medical Billing

A new bill, expected to be introduced this month by Sens. Joseph Lagana (D-Paramus) and Vin Gopal (D-Ocean Township)  is set correct some unintended consequences of the out-of-network law (NJ Healthcare Price Transparency Law) passed earlier this year, writes ROI NJ. While the previous bill sought to define how insurers pay doctors for services, it has caused confusion and acrimony, with the law seen to be favoring insurance companies and took negotiating power away from doctors who are not “in network” — and that the law was a strategy to force doctors into networks.

The new Lagana-Gopal bill attempts to clarify and redefine three of the measures in the bill, including:

Setting a guideline of payment for care:  The Lagana-Gopal bill would use guidelines from FAIR Health, a national independent, not-for-profit, to determine a minimum reimbursement, as the previous law does not dictate what a procedure costs, leaving it up to doctors and insurers to debate. Doctors and insurers can still debate the cost — based on a variety of other factors such as where the procedure is performed and the expertise of the doctor — but FAIR Health would provide a starting point.

Arbitration rules: The law calls for baseball-style arbitration — which means a third-party can only choose one payout amount between the originally billed amount and the insurance payout amount. But the law also says that in order for a claim to go through arbitration, it needs to have a difference of $1,000. If it’s not, doctors have to take what the insurers determine is fair-market value. The Lagana-Gopal bill would remove the $1,000 minimum. The change is an attempt to make the original bill more representative of the services provided.

Determining what actually is a surprise: The Lagana-Gopal bill will ask for the Department of Insurance and Banking to better define “inadvertent” out of network care.

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