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Ohio House Passes Bill 388 Including Out-of-Network Reimbursement Requirements

On May 20, 2020, the Ohio House of Representatives unanimously passed House Bill 388, which would enact five new Ohio Revised Code sections regarding out-of-network care and reimbursement. Sponsored by Representative Adam Holes – District 97 – House Bill 388 would require a health plan issuer to reimburse the following: 

  • An out-of-network provider for unanticipated out-of-network care provided at an in-network facility. 
  • An out-of-network provider or emergency facility for emergency services provided at an out-of-network emergency facility. 
  • An out-of-network ambulance for emergency services provided in an out-of-network ambulance. 
  • An out-of-network provider or facility for clinical laboratory services provided in connection with unanticipated out-of-network care or emergency services. 

As used above, "unanticipated out-of-network care" means health care services, including clinical laboratory services, that are covered under a health benefit plan and that are provided by an out-of-network provider when either of the following conditions applies: (1) the covered person did not have the ability to request such services from an in-network provider; or (2) the services provided were emergency services.

In addition to the above requirements, House Bill 388 also sets forth the following: 

  • Prohibits a provider, facility, emergency facility, or ambulance from balance billing a patient for unanticipated or emergency care when that care is provided in Ohio. 
  • Provides that a covered person’s cost-sharing responsibility for the services described above cannot be greater than if the services were provided in network. 
  • Establishes the default reimbursement rate as the greatest of the in-network rate, the out-of-network rate, or the Medicare rate and establishes procedures by which payees (providers, facilities, emergency facilities, and ambulances) may seek to negotiate the reimbursement in lieu of the default reimbursement rate. 
  • Permits certain payees to seek arbitration if negotiation is unsuccessful, and establishes criteria to be eligible for arbitration, and establishes procedures for the conduct of the arbitration. (Requires the Superintendent of Insurance to select an arbitration entity to conduct arbitrations under the bill using specified criteria). 
  • Requires a provider to disclose certain information to patients regarding the cost of out-of-network services that are not unanticipated out-of-network care or emergency services. 

The requirements found in House Bill 388 would be effective nine months following the bill’s effective date. Any payee or issuer in violation of these requirements would face disciplinary actions and/or penalties. The bill now continues the rule making path and will be debated and voted on by the Ohio Senate.

Please contact a BMD healthcare attorney if you have any questions regarding House Bill 388, any other reimbursement question, or other general healthcare questions.

New York, Kansas, Massachusetts, and Delaware Become the latest States to Adopt Full Practice Authority for Nurse Practitioners

While the COVID-19 pandemic certainly created many obstacles and hardships, it also created many opportunities to try doing things differently. This can be seen in the instant rise of remote work opportunities, telehealth visits, and virtual meetings. Many States took the challenges of the pandemic and turned them into an opportunity to adjust the regulations governing licensed professionals, including for advanced practice registered nurses (APRNs).

Explosive Growth in Pot of Gold Opportunity for Bank (and Other) Cannabis Lenders Driving Erosion of the Barriers

Our original article on bank lending to the cannabis industry anticipated that the convergence of interest between banks and the cannabis industry would draw more and larger banks to the industry. Banks were awash in liquidity with limited deployment options, while bankable cannabis businesses had rapidly growing needs for more and lower cost credit. Since then, the pot of gold opportunity for banks to lend into the cannabis industry has grown exponentially due to a combination of market constraints on equity causing a dramatic shift to debt and the ever-increasing capital needs of one of the country’s fastest growing industries. At the same time, hurdles to entry of new banks are being systematically cleared as the yellow brick road to the cannabis industry’s access to the financial markets is being paved, brick by brick, by the progressively increasing number and size of banks that are now entering the market.

2021 EEOC Charge Statistics: Retaliation & Impact of Remote Work

The U.S. Equal Employment Opportunity Commission (EEOC) released its detailed information on workplace discrimination charges it received in 2021. Unsurprisingly, for the second year in a row, the total number of charges decreased as COVID-19 either shut down workplaces or disconnected employees from each other. In 2021, the agency received a total of approximately 61,000 workplace discrimination charges - the fewest in 25 years by a wide margin. For reference, the agency received over 67,000 charges in 2020, and averaged almost 90,000 charges per year over the previous 10 years.

Ohio’s Managed Care Overhaul Delayed – New Implementation Timeline

At the direction of Governor Mike DeWine, the Ohio Department of Medicaid (ODM) launched the Medicaid Managed Care Procurement process in 2019. ODM’s stated vision for the procurement was to focus on people and not just the business of managed care. This is the first structural change to Ohio’s managed care system since the Centers for Medicare & Medicaid Services' (CMS) approval of Ohio’s Medicaid program in 2005. Initially, all of the new managed care programs were supposed to be implemented starting on July 1, 2022. However, ODM Director Maureen Corcoran recently confirmed that this date will be pushed back for several managed care-related programs.

Laboratory Specimen Collection Arrangements with Contract Hospitals - OIG Advisory Opinion 22-09

On April 28, 2022, the Department of Health and Human Services, Office of Inspector General (“OIG”) published an Advisory Opinion[1] in which it evaluated a proposed arrangement where a network of clinical laboratories (the “Requestor”) would compensate hospitals (each a “Contract Hospital”) for specimen collection, processing, and handling services (“Collection Services”) for laboratory tests furnished by the Requestor (the “Proposed Arrangement”). The OIG concluded that the Proposed Arrangement would generate prohibited remuneration under the federal Anti-Kickback Statute (“AKS”) if the requisite intent were present. This is due to both the possibility that the proposed per-patient-encounter fee would be used to induce or reward referrals to Requestor and the associated risk of improperly steering patients to Requestor.