44-4220.02 Review of health care provider reimbursement rates; report; health care provider; reimbursement; other payments.
44-4220.02. Review of health care providerreimbursement rates; report; health care provider; reimbursement; other payments.(1)(a)In addition to the requirements of section 44-4220.01, following the closeof each calendar year, the board shall conduct a review of health care providerreimbursement rates for benefits payable under pool coverage for covered services.The board shall report to the director the results of the review within thirtydays after the completion of the review.(b) Thereview required by this section shall include a determination of whether (i)health care provider reimbursement rates for benefits payable under pool coveragefor covered services are in excess of reasonable amounts and (ii) cost savingsin the operation of the pool could be achieved by establishing the level ofhealth care provider reimbursement rates for benefits payable under pool coveragefor covered services as a multiplier of an objective standard.(c) Inthe determination pursuant to subdivision (1)(b)(i) of this section, the boardshall consider:(i)The success of any efforts by the administering insurer to negotiate reducedhealth care provider reimbursement rates for benefits payable under pool coveragefor covered services on a voluntary basis;(ii)The effect of health care provider reimbursement rates for benefits payableunder pool coverage for covered services on the number and geographic distributionof health care providers providing covered services to covered individuals;(iii)The administrative cost of implementing a level of health care provider reimbursementrates for benefits payable under pool coverage for covered services; and(iv)A filing by the administering insurer which shows the difference, if any,between the aggregate amounts set for health care provider reimbursement ratesfor benefits payable under pool coverage for covered services by existingcontracts between the administering insurer and health care providers andthe amounts generally charged to reimburse health care providers prevailingin the commercial market. No such filing shall require the administering insurerto disclose proprietary information regarding health care provider reimbursementrates for specific covered services under pool coverage.(d)If the board determines that cost savings in the operation of the pool couldbe achieved, the board shall set forth specific findings supporting the determinationand may establish the level of health care provider reimbursement rates forbenefits payable under pool coverage for covered services as a multiplierof an objective standard.(2)A health care provider who provides covered services to a covered individualunder pool coverage and requests payment is deemed to have agreed to reimbursementaccording to the health care provider reimbursement rates for benefits payableunder pool coverage for covered services established pursuant to this section.Any reimbursement paid to a health care provider for providing covered servicesto a covered person under pool coverage is limited to the lesser of billedcharges or the health care provider reimbursement rates for benefits payableunder pool coverage for covered services established pursuant to this section.A health care provider shall not collect or attempt to collect from a coveredindividual any money owed to the health care provider by the pool. A healthcare provider shall not have any recourse against a covered individual forany covered services under pool coverage in excess of the copayment, coinsurance,or deductible amounts specified in the pool coverage. Nothing in this sectionshall prohibit a health care provider from billing a covered individual underpool coverage for services which are not covered services under pool coverage. SourceLaws 2009, LB358, § 3.