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

BILL NUMBER:S5374

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 of bill

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 specific provisions

Section 1. Section 4406 of the public health law by adding a new subdivision 6. The new subdivision provides when the participant or enrollee is referred to non-participating medical providers by in-network medical providers, the services must be reimbursable under the plan; requiring the out-of network to bill the in-network organization directly for services performed. Any payment made by the medical provider directly to the participant rather than to the out-of-network provider will not satisfy the organization's payment obligation to the clinical laboratory.

Section 4804 of the insurance law is amended by adding a new subsection (g) to 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 healthcare 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

Prior legislative history

A11385 of 2010

01/27/11 referred to health 03/25/11 reference changed to insurance 01/04/12 referred to insurance

Fiscal implications for state and local governments

None.

Effective date

This act shall take effect immediately