Bill > A1036

Introduced Session

This bill prohibits a health insurance claims payer from using downcoding in a manner that prevents a health care provider from submitting a health benefits claim for the actual service performed and collecting reimbursement from the payer for that service. The bill applies to health insurance carriers, organized delivery systems, or any agents of a health insurance carrier or organized delivery system doing business in New Jersey. Downcoding refers to the practice of adjusting health benefits claims submitted to a payer to a less complex or lower cost service than the service actually performed so the payer can reimburse a lower amount to the health care provider that submitted the claim. Downcoding may occur where a payer disputes a specific service or contends that the diagnosis did not require the specific service code submitted by the health care provider. Excessive or routine downcoding can significantly reduce revenue for health care providers. Health care providers are already subject to robust State laws concerning fraud relating to health benefits claims. These laws, including the "New Jersey False Claims Act," the "New Jersey Health Care Claims Fraud Act," and the "New Jersey Insurance Fraud Prevention Act," penalize health care providers that submit fraudulent claims to a payer.

Committee Categories

Nancy Muñoz (R)*, 

Introduced, Referred to Assembly Financial Institutions and Insurance Committee (on 01/09/2024)

Official Document