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Disclosure Requirements in Non-Emergent Cases – NJ

The Out-of-Network Consumer Protection Transparency Cost Containment and Accountability Act was adopted in June 2018 and went into effect last month.  It has gotten significant attention regarding emergent or urgent services rendered to patients, and the inability of out-of-network providers and facilities to balance bill the patient.  However, physicians should not overlook the disclosure requirements imposed by this bill on in-network and out-of-network providers rendering non-emergent services.

Regardless of the provider’s participation status with health care plans, they are required to provide the patient with a list of health care plans with which they participate.  Additionally, if services are to be rendered at a licensed facility, the provider must disclose to the patient with which facilities the provider is affiliated.  The provider may also have a duty to inform the patient about other providers that may be involved in the patient’s care.

If the physician is an out-of-network provider, then the disclosure requirements are even more onerous, and include informing the patient that they may request an estimate of the amount the provider will bill them for the services.  If the patient requests the estimated cost, the provider must also provide the patient with the anticipated CPT codes, and direct them to contact their insurance company for further information about their potential financial responsibility.

It is important to remember that simple disclosure by the provider of their network status is not sufficient to meet the statute’s definition that the patient “knowingly” elected to utilize the services of an out-of-network provider.  The statute sets forth requirements, some of which are referenced above, that would meet the definition, and allow the provider to pursue collection of their fees from the patient.

It is important to note that the regulations corresponding to the statute have not been adopted at this time, and accordingly, this post may need to be amended or clarified once the relevant regulations are adopted.

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