Here at Spark Health Partners, our experts keep a close eye on regulatory updates in the healthcare industry that could impact revenue cycle processes. This helps to keep our operators informed as well as to ensure our partners can stay one step ahead of shifting legislation.
In follow-up to our recent article on topics and bills that were pending in state legislatures, let’s take a look at what’s been recently enacted in three of those states.
Florida
Transparency in Health
and Human Services:
This legislation
includes:
- new requirements with respect to the collection of medical debt, including the imposition of a 3-year statute of limitations, and restrictions against taking “extraordinary collection actions” which include preemptively engaging in certain collection actions (e.g. selling debt, credit reporting, etc.) prior to meeting certain requirements (e.g. providing an itemized bill, making reasonable efforts to check eligibility for financial assistance, etc.
- new requirements for the provision of good faith estimates*; and
- new billing requirements, including required disclosures for cost sharing amounts as compared to cash payments for the same service/item, the establishment of an internal process for reviewing and responding to grievances from patients (the process must also allow a patient to dispute charges that appear on the patient’s itemized statement or bill and provide directions for doing so in bolded print on the bill).
*Note that the requirements for good faith estimates are not effective until the federal government issues a corresponding rule.
Maine
An Act to Provide for
Consistent Billing Practices by Health Care
Providers:
This new law requires that claims
for facility services submitted to health insurance
carriers identify the physical location where services
are rendered, including hospital off-campus locations.
An Act to Amend the
Maine Insurance Code Regarding Payments by Health
Insurance Carriers to Providers:
This new
law restricts health insurance carriers to filing
notices of a proposed amendment to a provider agreement
to only four time per calendar year: on January 1, April
1, July 1 and October 1.
If the proposed change
is to a reimbursement policy and it will impact more
than $500k per year to participating providers, then the
notice must include the carrier’s good faith estimate of
the total annual financial impact to all participating
providers in the state.
Carriers will need to furnish the participating provider with both a clean and redlined copy of the provider agreement being changed. This bill also shortens the time limits for carriers to retroactively deny previously paid claims to not more than 12 months. Situations exempt from the 12-month timeframe will now be subject to a 36-month limit.
An Act to Protect a
Patient’s Access to Affordable Health Care with
Timely Access to Health Care Prices:
This
new law requires health care facilities and
practitioners to post a notice informing patients of the
right of an uninsured patient to request information
about the price of medical services, and to include the
notice in the consent-to-treatment form that patients
sign before receiving health care services. Upon request
of an uninsured or self-pay patient, the new law
requires facilities and providers to furnish a good
faith estimate of the cost of medical services for that
single encounter within specified timeframes.
To a certain extent, these requirements align with current requirements under the Federal No Surprises Act (NSA), and a health care entity does not violate this state law if it complies with NSA requirements. If the provider fails to give an uninsured or self-pay patient a good faith estimate upon their request, then the provider is prohibited from initiating or pursuing any collection action against that patient for those items or services.
This new law also requires the provision of a description of services for a single encounter to insured patients upon their request. The description must include the CPT codes for the services and a notification that the patient may use the estimate to obtain an estimate of their out-of-pocket costs from their health insurance carrier. Carriers are then required to respond to requests from a patient for an estimate based on the description and codes given by the provider.
Lastly, the new law requires hospitals to comply with federal price transparency requirements.
An Act to Prohibit
Unfair Practices Related to the Collection of
Medical Debt:
This new law prohibits unfair
practices related to the collection of patient medical
debt, including the collection of any interest or fees
on the debt.
If pursuing litigation to compel payment of medical debt, the new law requires providing the patient with a certain written notice indicating that litigation may not be pursued when the consumer’s household income is not more than 300% of the federal poverty level, and then allowing the consumer 30 days to respond and provide evidence of their income.
An Act Concerning
Prior Authorizations for Health Care Provider
Services:
This new law permits a provider
who is actively treating an enrollee to act as their
representative for purposes of filing an appeal or
grievance without requiring prior authorization from the
enrollee. The provider, however, must furnish the
enrollee with notice of such at least 14 days prior to
filing the appeal or grievance and within 7 days after
filing, and the enrollee may affirmatively object to
such representation.
This new law requires carriers to allow prior authorizations to be effective for 14 days before or after the approved date if the service cannot be delivered on the approved date. For non-emergency services, the new law prohibits carriers from denying claims for those services so long as they were within the scope of the enrollee’s coverage pending medical necessity review. Carriers may also not impose a penalty on the provider for failing to obtain a prior authorization of greater than 15% of the contractually allowed amount for the services that required prior authorization approval.
This new law prohibits carriers from requiring prior authorization for post-evaluation or post-stabilization services provided during the same encounter. If post-evaluation or post-stabilization services require inpatient care, then the carrier may require prior authorization but it must respond to the prior authorization request within 24 hours. If the provider does not receive a determination within that 24-hour period, then the care is deemed approved until the carrier notifies the provider otherwise.
Lastly, this new law imposes new reporting requirements on carriers relating to prior authorization determinations, which will be collected by the Bureau of Insurance and reported to the Maine Legislature in 2025.
Virginia
An Act relating
to health insurance; ethics and fairness in carrier
business practices.
This bill made various
amendments to Va. Code § 38.2-3407.15, Ethics and
Fairness in Carrier Business Practices, including
revisions to the definition of a “clean claim.”
Regarding retroactive denials of previously paid
claims, this was broadened to include any way in
which a carrier may seek recovery or refund of a
previously paid claim. The time limit is 12 months
except that a provider and carrier may agree to
longer than 12 months for a retroactive denial. If a
carrier’s claim denial is overturned following a
dispute review, the carrier must consider the claim
be a “clean claim” on the day of its decision.
A newly enacted provision prohibits providers from filing a complaint with the State Corporation Commission for a carrier’s failure to pay claims as required unless the provider attests that they have made a reasonable effort to resolve the issue with the carrier and at least 30 calendar days have passed without response from the carrier.
An Act
relating to health insurance; prior
authorization.
Requires
provider-carrier contracts to include a specific
provision that if a prior authorization request
is approved for prescription drugs and such
prescription drugs have been scheduled, provided
or delivered to the patient consistent with the
authorization, the carrier shall not revoke,
limit, condition, modify or restrict that
authorization except in certain limited
situations.
An Act
relating to reporting of medical debt to
consumer reporting agencies by certain
health care providers.
Prohibits
facilities and providers from reporting any
portion of medical debt to a consumer reporting
agency. Further, collection entities collecting
or attempting to collect a medical debt are
prohibited from reporting such collection or
attempts to a consumer reporting agency. Any
willful violation of this new section
constitutes a prohibited practice under the
Virginia Consumer Protection Act.
An Act to
amend relating to health insurance; health
care provider panels; continuity of care.
Requires
a provider to continue to render health care
services to any of the carrier’s enrollees who
have an existing provider-patient relationship
with the provider for a period of at least 90
days from the date of a provider’s termination
from the carrier’s provider panel. Longer
periods required for patients who are pregnant
or terminally ill, who have a life-threatening
condition or who have been admitted inpatient.
Keeping you informed
Close monitoring of changing regulations is critical for the financial health of our clients and for any healthcare provider. Spark is committed to tracking new legislation as it is drafted and passed. Stay abreast of these latest developments by subscribing to our monthly newsletter, Spark Exclusive.
These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Spark Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.