The Missouri Congress passed Senate Bill 514 on May 16, 2019, and House Bill 399 on the following day. These bills revise Mo. Rev. Stat. § 376.690 to require physicians and other health care professionals to negotiate and, possibly, arbitrate claims for unanticipated out-of-network health care rendered at an in-network facility.

In all cases, except when the out-of-network provider renders services to a patient that presented to the facility with an emergency medical condition, the out-of-network provider may still bill the patient’s health insurer and receive the out-of-network payment rate.

However, that is no longer the case if the patient presents to a facility with an emergency medical condition, which is defined as “the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity, regardless of the final diagnosis that is given, that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that immediate medical care is required…” In that situation, the out-of-network provider that treats the patient (at any point between the patient presenting to the facility and his or her discharge) will be required to negotiate its payment rate with the patient’s insurer, and potentially, undergo arbitration if the provider and insurer cannot agree to an acceptable rate. In such an arbitration, the award is limited to a dollar amount:

“…between one hundred twenty percent of the Medicare-allowed amount and the seventieth percentile of the usual and customary rate for the unanticipated out-of-network care, as determined by benchmarks from independent nonprofit organizations that are not affiliated with insurance carriers or provider organizations.”

Regardless of whether the payment rate for such care is negotiated or arbitrated, the provider cannot bill the patient the difference between the negotiated or arbitrated amount and the provider’s usual billed charges. The provider is limited to collecting the in-network deductible and out-of-pocket maximum from the patient.

The attorneys of Lashly & Baer, P.C. have significant experience in negotiating and arbitrating provider payment rates. If you have any questions or concerns, please do not hesitate to give our attorneys a call, at 314-621-2939.

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