Bill > A504

Introduced Session

This bill is intended to provide remedies for individuals who are treated by physicians and treated in facilities that do not belong to a provider network used by the individual's health benefits plan and who are consequently billed for the balance of charges that are not paid for by their health benefits plan. In order to provide such services and to provide transparency in the health care system, the bill requires that at the time a non-emergency medical procedure or other health care service is scheduled for a covered person, a physician must disclose to the patient whether or not he is a participating physician in the health benefits plan in which the covered person is a member. If the physician is a non-participating physician, the covered person will have the option of either finding an alternative physician or selecting the non-participating physician. If the patient knowingly selects a non-participating physician, the physician would be required to provide a written estimate of the probable cost of the procedure or service, not including unforeseen medical circumstances that may arise when the procedure or service is provided. The non-participating physician must secure the written assent of the patient to pay any balance that is in excess of the amount paid by the person's health benefits plan. The covered person must be informed that he will have a financial responsibility with respect to the services that are provided. The physician also has to provide the covered person with information regarding any other physician or group of physicians whose ancillary services are to be utilized by the attending physician, as well as information as to how the patient can determine whether the ancillary physician or physicians are in the patient's network, thus avoiding what has been called "surprise" balance billing. The same requirements would apply to hospitals, which would have to inform patients that their facility-based physicians, including staff physicians, radiologists, and anesthesiologists who bill separately, may not be in the patient's health benefits plan network. The disclosure provisions will not apply in any case in which the treatment takes place on an emergency or urgent basis; in that case the physician or hospital cannot require the patient to pay any amount in excess of whatever reimbursement was made by his health benefits plan. While physicians and health care facilities clearly know if they are in a network organized by an insurance carrier, nearly 70 percent of individuals covered by health benefits plans in the State are in self-insured plans, in which their employers are paying the claims out of its own funds, assuming all of the risk themselves. Self-insured plans are almost always administered by licensed third party administrators, although a few employers process the claims themselves. These administrators contract with networks of physicians and health care facilities, including preferred provider organizations, to provide health care services at a reduced rate, much as health insurers do with their networks. Because of this, a physician or health care facility would not necessarily know if they are a member of a network used by an independent third party administrator; often the health benefits card carries the name of the employer rather than a recognizable insurance company or third party administrator. Because the bill requires disclosure of network status by all physicians and health care facilities, it requires third party administrators to notify every physician or facility that is in a network that they use with the name of the administrator's employer clients so that a physician or facility will be alerted that they are in a network of a health benefits plan of a patient working for a specific employer. In the event that a patient or insurer or third party administrator receives a balance bill from a physician or facility, the bill provides two peer review mechanisms - one for physicians and one for health care facilities. The physicians' peer review panel, established in the Physicians' Medical Bill Dispute Resolution Review Program and located in the State Board of Medical Examiners, consists of 21 physicians of different specialties, appointed by the Governor. The health care facilities peer review panel, the Health Care Facilities Medical Bill Dispute Resolution Program, will be comprised of a board of 11 members representing health care facilities located in this State, who shall be appointed by the Governor in consultation with the New Jersey Hospital Association. A panel of three physicians or facilities will be assigned to each case. The bill does not provide for so-called "baseball-style arbitration," in which an all-or-nothing award is made relative to a disputed amount, but rather sets forth a number of criteria that should be considered by the peer review panel, and permits the panel to award any amount it would determine to be fair. The decision of the panel would be determinative.

AI Summary

Committee Categories

Bob Auth (R)*, 

Introduced, Referred to Assembly Financial Institutions and Insurance Committee (on 01/13/2026)

Official Document