FIVE FACTS ABOUT THE EMERGENCY CARE BILL HOSPITALS MUST FOLLOW
- An Out of Network provider cannot charge more than the copayment, coinsurance or deductible required of your network providers for emergency care;
- If you are stable, an out-of-network hospital must transfer you to an in network provider within 24 hour of admission;
- If the hospital had a contract within the preceding 12 months that was terminated, the health insurer is required to pay as if they were still on the plan and the hospital must accept.
- Hospitals are required to negotiate directly with the insurance company;
- Medicaid patients are exempt from the bill.
Nevada Gov. Steve Sisolak has signed a law to protect patients from “surprise medical bills” after emergency treatment. The legislation puts limits on the cost an out-of-network provider can charge a patient for specific medically necessary emergency services. That cost under this legislation is limited to a patient’s insurance copay, coinsurance or deductible. The bill has a provision for a process that determines the amount of reimbursement from insurers out-of-network providers can charge for emergency services. In addition, it is a required process for out-of-network providers to transfer patients to a hospital that is in the patient’s insurance network within 24 hours.
This legislative action that reforms billing practices was signed into law by Governor Sisolak on May 15, 2019 and limits the amount a provider of health care may charge a person who has health insurance for certain medical emergency services provided when the provider is out-of-network. The bill is comprised of several sections including a provision that requires an insurer to arrange for the transfer of a person who has health insurance to an in-network facility under certain circumstances. It also has provisions for determining the amount that an insurer (aka the health insurance company) is required to pay an out of network provider for specific medically necessary emergency services. When such services are provided to a patient, there are also provisions that require the reporting of certain information related to the treatment.
The complete bill can be reviewed at: https://www.leg.state.nv.us/App/NELIS/REL/80th2019/Bill/6896/Text
Currently, under Nevada Law, a hospital is required to provide emergency services and treatment (including admission to the hospital when needed) to certain patients, regardless of the financial status of the patient. (See NRS 439B.410) Existing law further requires specific major hospitals to reduce total billed charges by at least 30 percent for hospital services provided to certain patients who have no insurance or other contractual provision for the payment of the charges by a third party, which is an insurer. (NRS 439B.260) The bill defines the phrase “out of network provider” “as for a particular person covered by a policy of health insurance, a provider of health care or medical facility that has not entered into a contract with a third party for the provision of health care to persons who are covered by a policy of insurance issued by that third party.”
This bill is a much needed addition to Nevada Healthcare law and protect patients from “surprise” medical bills. Much more healthcare reform is needed in Nevada to protect patients. Below is an outline of the recently passed legislation:
Section 11 — This section exempts services provided to recipients of Medicaid from the provisions of this bill.
Section 13 –This section exempts a critical access hospital and a person covered by a policy of insurance sold outside Nevada from the provisions of this bill.
Section 14–This section prohibits an out of network provider from collecting against a person covered by a policy of health insurance an amount for medically necessary emergency services that exceeds the copayment, coinsurance or deductible required by that policy. In addition, Section 14 also requires an out of network hospital or independent center for emergency medical care that provides medically necessary emergency services to a covered person to notify the third party that provides coverage for the person that:
(1) the person is receiving such services at the facility; and
(2) the person’s emergency medical condition is stabilized not later than 24
hours after such stabilization occurs.
Section 14 further requires the third party to arrange for such a
transfer to an in network hospital or independent center for emergency medical care
not later than 24 hours after receiving such notice. If an out of network hospital or independent center for emergency medical care had a contract as an in network hospital or independent center for emergency medical care with the third party that provides coverage for the covered person within the 12 months immediately preceding the provision of medically necessary emergency services to a covered person.
section 15 of this bill requires the third party to pay, and the hospital or independent center for emergency medical care to accept, as compensation for those services an amount based on the amount that would have been paid for those services under the most recent contract between the third party and the hospital or independent center for emergency medical care. If an out of network hospital or independent center for emergency medical care did not have a contract as with the third party that provides coverage for the covered person as an in network hospital or independent center for emergency medical care during that time, section 15requires the third party to pay to the provider an amount that the third party has determined to be fair and reasonable as payment for the medically necessary emergency services.
Section 16 has similar provisions applicable to out of network providers, other than hospitals and independent centers for emergency medical care. Specifically, if an out of network provider had a contract as an in network provider with the third party that provides coverage for the covered person within the 12 months immediately preceding the provision of medically necessary emergency services to a covered person
that was not terminated by the third party for cause, this section requires the
third party to pay, and the provider to accept, as compensation for those services an
amount based on the amount that would have been paid for those services under the
most recent contract between the third party and the provider. If an out of network
provider did not have a contract with the third party that provides coverage for the
covered person as an in network provider during that time or if such a contract was terminated by the third party for cause section 16 requires the third party to pay to the provider an amount that the third party has determined to be fair and reasonable as payment for the medically necessary emergency services.
Section 17 – Requires that the out of network providers request from the third party an additional amount which, when combined with the amount previously paid, the out of network provider is willing to accept as payment in full and if not paid, the parties are required to submit the dispute to binding arbitration. This section also states that interest cannot accrue on a claim during the arbitration process.
Sections 21 – 27of this bill make conforming changes. Sections 17, 19and 20 of this bill provide for the confidentiality of the decisions of arbitrators and documents associated with arbitration.
Section 18 of this bill authorizes certain health insurers not included in this bill to opt in to the provisions of the bill.
Section 19 of this bill provides for the annual reporting of certain information concerning arbitrations conducted.
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