As of September 2018, the “Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act,” (New Jersey) puts forward an effort to regulate out-of-network (“OON”) billing and prevent patients from receiving “surprise bills” for excessive amounts. The act now requires insurers to pay out of network physicians directly for their care. The bill applies to emergency and “inadvertent” care, meaning care provided by out-of-network physicians in in-network settings (i.e. hospital-based physicians), including but not limited to anesthesiologists and radiologists. The bill applies to state-regulated insurance plans but not to federally regulated self-funded plans (most of New Jersey’s insurance market), UNLESS a self-funded plan opts in to participate in the arbitration program.
There can be many reasons for ‘inadvertent’ OON care, for example
What this means is that “a covered person’s liability for services rendered during a hospitalization in a network hospital, including, but not limited to, anesthesia and radiology, where the admitting physician is a network or out-of-network provider and the covered person and/or provider has complied with all required preauthorization or notice requirements, shall be limited to the copayment, deductible and/or coinsurance applicable to network services.” An OON provider may not waive, rebate, give, or pay all or part of the patient’s in-network cost-sharing obligation as an inducement for the patient to seek health care services from that provider.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.