Arbitrations

A-2039 New Jersey Mandate

The Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act, (P.L.2018, c.32), (“Act”), was signed into law on June 1, 2018, and became effective on August 30, 2018. This Act provides enhanced protections for consumers who receive health care services from out-of-network providers at a participating hospital for urgent, emergent, and inadvertent care.
You may file C.32 OON arbitration application if it meets the eligibility listed below:

  1. On the date of service, the covered person was enrolled in an insured benefits plan issued in New Jersey, a self -funded plan that opts in to C32 OON arbitration, the State Health Benefits Plan, the School Employees Health Benefits Plan, or a Multiple Employer Welfare Arrangement, and
  2. Services were rendered by an out-of-network provider, licensed, or certified in New Jersey, on or after August 30, 2018, on an inadvertent, emergency, or urgent basis.
  3. The carrier has determined the out-of-network provider’s billed charges to be excessive and negotiations between the out-of-network provider and the carrier in the 30-day period following claim finalization have not resulted in a settlement
  4. The difference between the carrier’s final offer and the out-of-network provider is $1000 or more.

While N.J.S.A. 26:2SS-1 to -20 permits out-of-network health care providers to apply for arbitration when they disagree with the carrier’s reimbursement for health care services rendered on an inadvertent, emergency, or urgent basis it presents with an additional hassle for providers. Our company will be happy to alleviate you of this headache. Today we have hundreds of awards of fair reimbursement in favor of our clients thus allowing them to maintain their focus on providing the highest level of patient care.

Capital Medical Billing Solutions has been at the forefront of filing provider arbitrations. To date, our company has filed the most arbitration cases in the state since the implementation of A-2039. Subsequently, we were invited to present evidence, showcasing inconsistencies and flaws in the arbitration process at New Jersey State Senate, thus contributing to a more streamlined arbitration process providers are more content with today.

Federal Legislation Arbitrations

The Federal No Surprises Act was enacted on January 1, 2022. Generally, the Act limits the amount an insured patient will pay for emergency services furnished by an out-of-network provider and the ancillary service received at an in-network facility. The plan will determine the cost-sharing expense based on the Recognized amount: All-Payer Model Agreement; determined by the Specified State Law or Qualifying Payment Amount (QPA). 

The Process: 

Following initial processing of the claim, the plan makes an initial payment or sends a denial. This amount represents the payor’s reasonable payment in full. Should the provider disagree with the reimbursement, they will enter a 30-day Negotiation Period. If no agreement has been reached, they may enter an independent dispute resolution (“IDR”) process with one of the certified IDR entities.  https://www.cms.gov/nosurprises/Help-resolve-payment-disputes/certified-IDRE-list

The IDR process is a “baseball-style” arbitration. The provider and insurer each submit a proposed payment amount and explanation to the arbitrator. The arbitrator must select one of the two proposed payment amounts taking into account the considerations such as: QPA, the level of training, experience, and quality and outcomes measurements of the provider or facility; the market share held by the nonparticipating provider or facility in the relevant geographic area; the acuity of the individual receiving such item or service or the complexity of furnishing such item or service to such individual; the teaching status, case mix, and scope of services of the nonparticipating facility; and demonstrations of good faith efforts made provider and payer to negotiate the claim. 

The Act prohibits the arbitrator from considering the provider’s usual and customary charges for an item or service, the amount the provider would have billed for the item or service in the absence of the Act, or the reimbursement rates for the item or service under the Medicare, Medicaid, Children’s Health Insurance, or Tricare programs. 

CMS enforced the states to develop state-by-state enforcement letters that delineate enforcement responsibilities. These letters clarify what provisions are enforced directly by the state, provisions that are enforced through a collaborative enforcement agreement, and provisions enforced by CMS. 

For a complete list of enforcement letters visit: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/CAA 

To learn more about the No Surprises Act, visit www.cms.gov/nosurprises