Bill Text: NJ S1137 | 2012-2013 | Regular Session | Introduced
Bill Title: Concerns processing and payment of insurance claims for physical therapy services.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2012-01-23 - Introduced in the Senate, Referred to Senate Commerce Committee [S1137 Detail]
Download: New_Jersey-2012-S1137-Introduced.html
Sponsored by:
Senator NIA H. GILL
District 34 (Essex and Passaic)
SYNOPSIS
Concerns processing and payment of insurance claims for physical therapy services.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning the practice of physical therapy, supplementing chapter 30 of Title 17B of the New Jersey Statutes, and amending P.L.1983, c.296.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. (New section) As used in sections 1 through 3 of this act:
"Affiliate" means a business entity that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, a licensed health care facility.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue a health benefits plan in this State.
"Claimant" means a physical therapy provider or a covered person claiming the right to receive payment from a payer or payer's agent for any covered physical therapy benefit.
"Commissioner" means the Commissioner of Banking and Insurance.
"Control," including the terms "controlled by" and "under common control," means the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of a business entity, whether through the ownership of voting securities, by contract or otherwise. "Control" shall not be construed to apply to a physical therapist's professional, legal, and ethical responsibilities for the practice of physical therapy consistent with State laws and regulations applicable to that practice.
"Covered person" means a person on whose behalf a payer or payer's agent is obligated to pay benefits or provide services pursuant to a health benefits plan.
"Covered physical therapy benefit" means: (1) a service of physical therapy provided by a physical therapy provider to a covered person; (2) payable to the physical therapy provider; and (3) at a rate not less than the rate established for the service by the applicable minimum payment schedule as set forth in this act.
"Health benefits plan" means a hospital or medical expense insurance policy, health service corporation contract, hospital service corporation contact, medical service corporation contract, health maintenance organization contract, or other contract, policy, or plan for hospital or medical care delivered or issued in this State. However, health benefits plan shall not include the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage arising out of a workers' compensation or similar law; and motor vehicle medical payment insurance or personal injury protection coverage provided by a motor vehicle or automobile insurance policy issued pursuant to Subtitle 3 of Title 17 of the Revised Statutes (C.17:17-1 et seq.) or P.L.1972, c.70 (C.39:6A-1 et seq.).
"Health care facility" means "health care facility" as defined by subsection a. of section 2 of P.L.1971, c.136 (C.26:2H-2).
"Minimum payment schedule" means the minimum payment schedule established pursuant to section 2 of this act, providing for the minimum amount of reimbursement of a covered physical therapy benefit pursuant to any health benefits plan.
"Network" means one or more physical therapy providers, which enter into a selective contracting arrangement with a carrier or organized delivery system.
"Organized delivery system" means "organized delivery system" as defined in section 1 of P.L.1999, c.409 (C.17:48H-1).
"Payer" means a carrier or organized delivery system assuming the financial risk of paying for a covered physical therapy benefit.
"Payer's agent" or "agent" means any agent of a payer, including, but not limited to, a third party administrator or third party billing service, providing authorization for covered physical therapy benefits, or administrative functions including, but not limited to, the payment of claims or the receipt, processing, or transfer of claims or claims information, without the assumption of a financial risk for any claims payment.
"Physical therapy" means "physical therapy" as defined in section 3 of the "Physical Therapist Licensing Act of 1983," P.L.1983, c.296 (C.45:9-37.13).
"Physical therapy provider" means an individual or other entity, except a licensed health care facility or an affiliate thereof, authorized to render, and be reimbursed for, physical therapy services under State law.
"Selective contracting arrangement" means an arrangement in which a carrier or organized delivery system participates in selective contracting with one or more physical therapy providers, and which arrangement contains reasonable benefit differentials, including, but not limited to, predetermined fee or reimbursement rates for covered physical therapy benefits applicable to participating and nonparticipating physical therapy providers.
2. (New section) Notwithstanding any provision of law to the contrary, with respect to any health benefits plan delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the commissioner:
a. A payer or payer's agent shall provide reimbursement to a claimant for any covered physical therapy benefit under a health benefits plan at a rate that is not less than the rate established for the benefit pursuant to a minimum payment schedule which shall be established and updated pursuant to this subsection. The minimum payment schedule shall be based upon rates that are 140% of the federal Medicare fee schedule rates in effect for the period beginning January 1, 2009 and ending June 30, 2009, using the single conversion factor for calendar year 2009 of $36.066, as established pursuant to section 1848(d) of the federal "Social Security Act," Pub.L.74-271 (42 U.S.C. s.1395w-4(d)). In calendar year 2010 and each calendar year thereafter, the minimum payment schedule shall be based upon the rates established the preceding calendar year, using the appropriate year's single conversion factor as updated, based on the percentage increase in the Medicare economic index as defined in section 1842(i)(3) of the federal "Social Security Act," Pub.L.74-271 (42 U.S.C. s.1395u(i)(3)).
b. A payer or payer's agent shall not calculate the reimbursement rate of any out-of-network physical therapy provider by using any negotiated, predetermined fee or reimbursement rate agreed to by any network of physical therapy providers pursuant to a selective contracting arrangement.
3 (New section) Notwithstanding any applicable claims authorization, processing, and payment provisions of P.L.1999, c.154 (C.17B:30-23 et al.) for health care claims, or any other law concerning any other health benefits plan claims, a payer or payer's agent shall not amend a claim for reimbursement for any covered physical therapy benefit by changing the diagnostic or treatment code assigned to the physical therapy benefit provided by the claimant.
4. Section 3 of P.L.1983, c.296 (C.45:9-37.13) is amended to read as follows:
3. As used in this act:
"Board" means the State Board of Physical Therapy Examiners established pursuant to section 5 of this act.
"Direct supervision" means the presence of the supervising physical therapist on site, available to respond to any consequence occurring during any treatment procedure.
"Physical therapist" means a natural person who holds a current, valid license to practice physical therapy pursuant to the provisions of this act and in accordance with regulations of the board. "Physical therapist assistant" means a natural person who is licensed pursuant to the provisions of this act and who assists a licensed physical therapist under his direct supervision in accordance with this act and regulations of the board.
"Physical therapy" or "physiotherapy," and "physical therapy practice" mean the identification of physical impairment or movement-related functional limitation that occurs as a result of injury or congenital or acquired disability, or other physical dysfunction through examination, evaluation and diagnosis of the physical impairment or movement-related functional limitation and the establishment of a prognosis for the resolution or amelioration thereof, and treatment of the physical impairment or movement-related functional limitation, which shall include, but is not limited to, the alleviation of pain, physical impairment and movement-related functional limitation by therapeutic intervention, including treatment by means of manual therapy techniques and massage, electro-therapeutic modalities, the use of physical agents, mechanical modalities, hydrotherapy, therapeutic exercises with or without assistive devices, neurodevelopmental procedures, joint mobilization, movement-related functional training in self-care, providing assistance in community and work integration or reintegration, providing training in techniques for the prevention of injury, impairment, movement-related functional limitation, or dysfunction, providing consultative, educational, other advisory services, [and] peer-review, independent examination services, collaboration with other health care providers in connection with patient care, and such other treatments and functions as may be further defined by the board by regulation.
(cf: P.L.2003, c.18, s.1)
5. Section 9 of P.L.1983, c.296 (C.45:9-37.19) is amended to read as follows:
9. No person shall practice physical therapy or act as a physical therapist assistant, whether or not compensation is received or expected, unless the person holds a valid license to practice physical therapy in this State; however, nothing in this section shall be construed to:
a. Prohibit any student enrolled in a school or post-graduate course of physical therapy or in a course of study for training as a physical therapist assistant that is approved or recognized by the board from performing physical therapy or acting as a physical therapist assistant, as appropriate, which is necessary to his course of study;
b. Prohibit any person licensed to practice in this State under any other law from engaging in the practice for which the person is licensed, provided that: the procedures or duties performed by that person are within the scope of that person's practice as established by law and the accepted standards of practice of the profession for which the person is licensed; and the person does not represent himself as a physical therapist or physical therapist assistant, or as practicing or offering to practice physical therapy; or
c. Prohibit any person employed by an agency, bureau or division of the federal government from practicing physical therapy within the scope of his official duties.
(cf: P.L.2003, c.18, s.5)
6. This act shall take effect on the first day of the 90th day following enactment, and shall apply to any health benefits plan delivered, issued, executed or renewed, or approved for issuance or renewal in this State, on or after the effective date; but the Commissioner of Banking and Insurance may take any anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.
STATEMENT
This bill reforms aspects of the processing and payment of insurance claims relating to the provision of physical therapy services by physical therapy providers, other than licensed health care facilities or their affiliates.
With respect to any claim for reimbursement under a health benefits plan, as defined in the bill, for any covered physical therapy benefit, the bill mandates that the calculation of any reimbursement by the payer shall be at a rate that is not less than the rate established for physical therapy benefits under a minimum payment schedule, which shall be based upon rates that are 140% of the federal Medicare rates.
Further, this calculation of reimbursement shall not be reduced with respect to any out-of-network physical therapy provider, based upon any negotiated, predetermined fee or reimbursement rate agreed to by any network of physical therapy providers pursuant to a selective contracting arrangement. This provision is intended to prevent the payer's use of so-called "silent" preferred provider organizations or other methods to justify the application of discounted fees or reimbursement rates to a physical therapy benefit provided by an out-of-network physical therapy provider.
Additionally with respect to reimbursement, the bill provides that, notwithstanding the provisions of the "prompt pay" law, P.L.1999, c.154 (C.17B:30-23 et al.), or any other law concerning health benefits plan claims, a payer shall not amend a claim for reimbursement for any covered physical therapy benefit by changing the diagnostic or treatment code assigned to the physical therapy benefit provided by the claimant.
The bill's provisions, once effective, shall apply to any health benefits plan delivered, issued, executed or renewed, or approved for issuance or renewal in this State, on or after the effective date; but the Commissioner of Banking and Insurance may take any anticipatory administrative action in advance thereof as shall be necessary for the implementation of the bill.
