Effective Jan. 1, 2020, a new law (HB19-1174) sets billing parameters and requirements for out-of-network (OON) services provided at an in-network facility. Examples include an out-of-network anesthesiologist, pathologist, radiologist, hospitalist, trauma surgeon or neonatologist. Physicians should become familiar with the new parameters and requirements and additional rules to be implemented before Jan. 1, 2020. The law does not apply to patients who intentionally seek services from an out-of-network provider.
New benchmark for OON reimbursement - The benchmark reimbursement rate by carriers to out-of-network providers is the greater of either: (a) 110% of the carrier's in-network reimbursement rate; or (b) The 60th percentile of the in-network reimbursement rate for the same service in the same geographic area from the All Payer Claims Database for the prior year.
New notification/disclosure requirement - The Division of Insurance, Division of Professions & Occupations (Medical Board), and Department of Health will develop the language and timing for facilities and physicians to notify patients and provide a disclosure to patients concerning the potential for receiving OON services and patient rights under Colorado law.
Estimate* - The OON physician must provide a written estimate to the patient within three business days of a request.
Timely claim filing* - The OON physician must submit a claim for the total amount to the patient's insurance carrier within 180 days of the date of service. If the claim is submitted beyond 180 days, then the physician will only be reimbursed at 125% of the Medicare rate for that service.
No balance billing* - Physicians can only collect any in-network cost-sharing amount from the patient. The insurance carrier is to send payment directly to the OON physician and inform the physician of the patient's required coinsurance, deductible or copayment.
Verification procedure - Any questions concerning the accuracy of the amount paid for OON services can be referred to the insurance commissioner for verification.
Arbitration procedure - The OON physician may initiate arbitration through the Division of Insurance to contest the reimbursement amount given the complexity and circumstances of the services provided within 90 days after receipt of payment. Prior to arbitration, the carrier and the physician may conduct an informal settlement teleconference. If the issue is not resolved the commissioner assigns an arbitrator. Each party submits their final "best" offer and the arbitrator will select one or the other (baseball arbitration). The loser pays the cost of the arbitration.
Refund of overpayment* - If the OON physician receives an overpayment from the patient, the physician must refund the overpayment amount within 60 days of receiving notice. If the OON physician does not refund the overpayment in time, then the physician must pay the patient interest at the rate of 10% per annum and include that amount with the refund.
*Failure to comply with these provisions is a deceptive trade practice in violation of CRS 6-1-105.