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As a provider, how often have you encountered the situation where a patient needs multiple procedures, but their insurance requires them to have each procedure done on a different day? For example, orthopedic surgeons have found situations where a hand surgery needs to be done on multiple fingers, but there is decreasing reimbursement for each finger after the first one. We also have gastroenterologists who need to perform different types of endoscopies, but the payers limit them to one endoscopy on the same patient in one day. There is also the “same tax ID” game where a patient can only see one provider under a single tax ID in one day, which is a problem when the patient could see a specialist on the same day as their primary care provider.

House Bill (HB) 429 may help fix these reimbursement issues. HB 429 was introduced in the Ohio House of Representatives on August 28, 2025 and seeks to amend O.R.C. 3901.385, which places certain prohibitions on third-party payers.

ORC 3901.385 currently prohibits third-party payers from (1) engaging in any business practice that unfairly or unnecessarily delays the processing of a claim or the payment of any amount due for health care services rendered by a provider to a beneficiary; and (2) from refusing to process or pay within the time periods specified in O.R.C. 3901.381 a claim submitted by a provider on the grounds the beneficiary has not been discharged from the hospital or the treatment has not been completed, if the submitted claim covers services actually rendered and charges actually incurred over at least a thirty-day period.

If passed by the Ohio General Assembly, HB 429 specifically proposes to add language prohibiting a third-party payer from reducing a provider’s reimbursement for the provision of a covered health care service based on (1) the third-party payer's own description of what is included in the specific service outside of the most current CPT code in effect, the most current ICD-10 code in effect, the most current CDT code in effect, or the most current HCPCS code in effect; (2) the third-party payer's own description of what is included in the diagnosis code submitted on the claim outside of guidelines established by entities responsible for the code set, including the centers for disease control and prevention's national center for health statistics; and (3) that the provider billed for additional health services, including outpatient surgery, on the same date as the covered service. The prohibitions that HB 429 proposes can have far reaching effects on provider reimbursement.

HB 429 is part of the Ohio State Medical Association’s insurance reform package that supports legislation seeking to protect patients’ interests and physician decision-making.[1]

To learn more about HB 429 and how the Bill could impact your practice, please contact BMD Member Jeana Singleton at jmsingleton@bmdllc.com.

[1] Insurance Reform, Ohio State Medical Association,  https://osma.org/aws/OSMA/pt/sp/insurance-reform, (last accessed September 11, 2025).