The first bill (S-1743), referred to as the “co-payment bill,” would make the waiver, rebate or payment of an insured’s deductible, copayment or coinsurance by a healthcare provider a form of insurance fraud and subject to criminal and civil penalties.
Mr. Manigan explains:
“Under the Copayment Bill, if a healthcare provider waives, rebates, gives, pays or offers to waive, rebate, give or pay all or part of the deductible, copayment, or coinsurance owed by a covered insured, the healthcare provider would be deemed to violate the New Jersey Insurance Fraud Prevention Act, resulting in penalties ranging between $5,000-$10,000.
“The healthcare provider would also be guilty of a crime of the fourth degree and would be subject to criminal penalties. Punishment for the conviction of crimes of the fourth degree can result in the imposition of a fine of up to $10,000 and imprisonment of up to 18 months. In addition, the healthcare provider would be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained, and could have his or her license or certificate suspended for a period of up to one year.”
The second bill (S-1742), referred to as the “notice bill,” would require a healthcare provider who participates in an insurance carrier’s network of providers to give written notice to a covered insured when that provider refers a covered insured to an out-of-network provider and the insured’s plan includes both in- an out-of- network benefits.
Mr. Manigan explains:
“The notice must contain a disclosure explaining the financial responsibility of the covered insured for deductibles, copayments and coinsurance, including a comparison of the covered insured’s responsibilities if the services were provided in-network. In addition, the notice must include a list of in-network providers that are available in that geographic area.”
Mr. Manigan calls these bills a “troubling intrusion into the provider/patient relationship,” and it appears that other ASC industry insiders agree.
Jeff Shanton, director of business management at Journal Square Surgical Center in Jersey City, N.J., says the bills are another attempt by insurance providers, with the help of state lawmakers, to end OON ASCs in the state.
“When everyone was giddy with the upholding of the Garcia case decision by the Appellate Court, I was cautioning people to be ready for the other shoe to drop, and this is it,” says Mr. Shanton. “Remember, the state of New Jersey, DOBI and all other major commercial carriers joined HealthNet against us at the Appellate level.”
