Tag Archives: clinical laboratory

New York State Legislative Bill Mandating Direct Payment To Out Of Network Clinical Laboratory Providers

The New York State Senate and Assembly have introduced a bill (S.1083/A.636) to amend the Public Health Law (Section 4406) and the Insurance Law (Section 4084), in relation to reimbursement of out-of-network clinical laboratory providers by a commercial health benefit plan.

The bill would require commercial health benefit plans to make payment for laboratory services directly to the out-of-network provider and deem any payment to the enrollee as insufficient to satisfy the payment obligation.

An interesting provision within the proposed mandate is that the enrollee remains responsible for any applicable copayment, deductible or coinsurance. However, the provision does not expressly condition the direct payment upon the clinical laboratory’s collection of the copayment, deductible or coinsurance from the enrollee.

The bill will be referred on January 9, 2013 to the Senate Committee on Health and the Assembly Committee on Insurance.

This post is contributed by Charles Dunham.

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Quest’s Competitors File Lawsuit for Prohibited Arrangements with National Health Plans

Over the past several years, some commercial insurers have made a concerted effort to reduce costs associated with laboratory services, which physicians have increasingly relied upon in diagnosing and treating patients. In particular, insurers are concerned with the rise in laboratory services being performed out-of-network and the increased costs associated with such claims. Despite the imposition of higher premiums for out-of-network benefits, insurers are attempting to do indirectly – what they cannot do directly – to restrict the ability of health plan members to receive laboratory services from out-of-network providers.

A federal complaint was filed on November 14, 2012, in the Northern District of California that highlights the extent of such activities alleged to have been taken by Aetna, Inc., Blue Shield of California, and Blue Cross and Blue Shield Association in violation of federal and state law, and charges that such efforts are being initiated in concert with Quest Diagnostics Incorporated, the largest clinical laboratory provider in the nation. Rheumatology Diagnostics Lab., Inc. et al v. Blue Shield of Cal. Life & Health Ins. Co. et al, Case No. 12-5847 (November 14, 2012).

In short the complaint alleges that Aetna and Blue Shield, in order to receive capitated rate discounts on laboratory services, have conspired with Quest to direct all laboratory testing business to Quest by controlling referrals and reducing competition by the following: Continue reading

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