Here at Ensemble 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. Ensemble is committed to tracking new legislation as it is drafted and passed. Stay abreast of these latest developments by subscribing to our monthly newsletter, Ensemble 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 Ensemble 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.