§ 44-4220.02 — Review of health care provider reimbursement rates; report; health care provider; reimbursement; other payments

Nebraska § 44-4220.02

• Jurisdiction: Nebraska
• Ch. 44: Insurance

Text

(1)(a) In addition to the requirements of
section 44-4220.01 , following the close of each calendar year, the board shall
conduct a review of health care provider reimbursement rates for benefits
payable under pool coverage for covered services. The board shall report to
the director the results of the review within thirty days after the completion
of the review.
(b) The review required by this section shall include a determination
of whether (i) health care provider reimbursement rates for benefits payable
under pool coverage for covered services are in excess of reasonable amounts
and (ii) cost savings in the operation of the pool could be achieved by establishing
the level of health care provider reimbursement rates for benefits payable
under pool coverage for covered services as a multiplier of an objective standard.
(c) In the determination pursuant to subdivision (1)(b)(i) of this section,
the board shall consider:
(i) The success of any efforts by the pool administrator to
negotiate reduced health care provider reimbursement rates for benefits payable
under pool coverage for covered services on a voluntary basis;
(ii) The effect of health care provider reimbursement rates for benefits
payable under pool coverage for covered services on the number and geographic
distribution of health care providers providing covered services to covered
individuals;
(iii) The administrative cost of implementing a level of health care
provider reimbursement rates for benefits payable under pool coverage for
covered services; and
(iv) A filing by the pool administrator which
shows the difference, if any, between the aggregate amounts set for health
care provider reimbursement rates for benefits payable under pool coverage
for covered services by existing contracts between the pool administrator and health care providers
and the amounts generally charged to reimburse health care providers prevailing
in the commercial market. No such filing shall require the pool administrator to disclose proprietary information
regarding health care provider reimbursement rates for specific covered services
under pool coverage.
(d) If the board determines that cost savings in the operation of the
pool could be achieved, the board shall set forth specific findings supporting
the determination and may establish the level of health care provider reimbursement
rates for benefits payable under pool coverage for covered services as a multiplier
of an objective standard.
(2) A health care provider who provides covered services to
a covered individual under pool coverage and requests payment is deemed to
have agreed to reimbursement according to the health care provider reimbursement
rates for benefits payable under pool coverage for covered services established
pursuant to this section. Any reimbursement paid to a health care provider
for providing covered services to a covered person under pool coverage is
limited to the lesser of billed charges or the health care provider reimbursement
rates for benefits payable under pool coverage for covered services established
pursuant to this section. A health care provider shall not collect or attempt
to collect from a covered individual any money owed to the health care provider
by the pool. A health care provider shall not have any recourse against a
covered individual for any covered services under pool coverage in excess
of the copayment, coinsurance, or deductible amounts specified in the pool
coverage.
(3) Nothing in this section
shall prohibit a health care provider from billing a covered individual under
pool coverage for services which are not covered services under pool coverage.

Legislative History

Source: Laws 2009, LB358, § 3; Laws 2011, LB73, § 3.