On May 18, 2018, the Missouri state legislature passed a bill benefitting Out-of-Network (OON) healthcare providers including physicians, hospitals, dentists, podiatrists, chiropractors, pharmacies, ambulance service providers, or optometrists. The bill directs insurance companies to directly pay OON Providers when services were authorized by the insurance company and creates obligations for insurance companies to make reasonable payment for unanticipated out-of-network care even if not granted a prior authorization. The bill still requires the governor’s signature and is expected to become law.
Beyond just requiring insurance companies make reasonable payment for unanticipated out-of-network care, the bill also provides a process to determine what is a reasonable payment. The insurance company and provider must negotiate in good faith to determine a reasonable payment. After 90 days of good faith negotiation, the OON provider may submit the payment dispute to binding arbitration oversaw by the Department of Insurance, Financial Institutions, and Professional Registration (DIFP). The DIFP arbitration must evaluate at least five separate factors to determine the reasonably reimbursement.
Additionally, the bill relieves patients from the obligation to make different payments between in-network and OON providers for unanticipated out-of-network care. This crucial section of the bill allows for providers to focus on care and treatment of the patient instead of heightened patient payments resulting from unanticipated out-of-network services.
If your OON practice is looking to take steps to document insurance company approval or obtain reasonable reimbursement for unpaid or underpaid unanticipated out-of-network care, contact Frier Levitt today to speak to an attorney.
