Relates to the reimbursement of out-of-network providers of clinical laboratory services

Title of bill

An act to amend the public health law and the insurance law, in relation to the reimbursement of out-of-network providers of clinical laboratory services by organizations providing or offering comprehensive health services plans

Purpose

To provide that organizations providing or offering comprehensive health services plans, such as managed care organizations and health maintenance organizations, directly reimburse out-of-network providers of clinical laboratory services when plan participants are referred to out-of-network providers by in-network organizations or providers.

Summary of provisions

Section 1 of the bill amends section 4406 of the public health law by adding a new subdivision 6. The new subdivision 6 provides that organizations providing or offering comprehensive health services plans must reimburse out-of-network providers of clinical laboratory services for the provision of such services to plan participants, when the participants are referred to out-of-network providers by in-network organizations or providers. The services must be of the type reimbursable under the plan. The bill would require the clinical laboratory to bill the organization directly for the services. Any payment made by an organization directly to the enrollee rather than to the clinical laboratory seeking reimbursement shall not satisfy the organization's direct payment obligation to the clinical laboratory.

Section 2 of the bill amends section 4804 of the insurance law by adding a new subsection (g) with provisions that are identical to the foregoing.

Justification

In an effort to provide the best health care available, health care organizations and providers regularly refer patients to providers outside of such patients' organization's networks. Under current law, however, such organizations are not required to directly reimburse out-of-network providers for clinical laboratory services rendered. Instead, out-of-network providers of clinical laboratory services must look directly to the patients for payment of their fees, even though patients are less likely to pay for the services once rendered and may assume that the organization is required to pay for the services. This provides a disincentive to out-of-network providers to render services to such patients even in cases where the out of network provider may offer better services. This practice also thwarts the medical advice and direction of the patient's medical care giver and limits patient health care options.

This legislation would expand the health care service options available to the residents of the state and promote the referral of patients to providers deemed to be the best for the medical care of such patients, whether in or out-of-network.

Legislative history

New bill.

Fiscal implications

None to the State. EFFECTIVE DATE : Immediately.