The New Jersey Department of Banking and Insurance (‘DOBI’) has published statistics tracking the number of Surprise Bill cases submitted to Maximus Federal, the DOBI contractor handling arbitration cases under the New Jersey Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act. Since the Act went into effect August 30, 2018, Maximus has received 5,715 requests for arbitration.
KEY FINDINGS:
- Of the total resolved arbitrations (5,428) with decisions issued, providers were awarded in 64% of the cases compared to the carriers prevailing in just 36% of the cases (total amounts awarded respectively, $31.4M vs $5.2M).
- Of the 5,715 cases submitted, 729 cases were withdrawn, and 813 cases were dismissed as ineligible with the leading reasons for dismissal:
- The health benefit plan was self-funded and did not opt-in (36%)
- However, as of January 28, 2021, 137 self-funded plans have opted-in to the arbitration process with 39 opting-in this year alone (January 2021)
- The health benefit plan was issued in a state other than New Jersey (29%)
- Did not negotiate/untimely negotiation/untimely arbitration (10%)
- The health benefit plan was self-funded and did not opt-in (36%)
As background, under the NJ Surprise Bill law, providers are prohibited from balance billing a covered person, for inadvertent out-of-network services and/or an emergency/urgent care, more than the covered person’s in-network cost sharing obligation (co-pays, deductible and co-insurance).
The Act primarily relies on negotiations between providers and payors (insurance companies and Self-Funded Plans that opted to be subject to the bill’s provisions) with disputes proceeding to the binding arbitration process. Based on the statistics published, the arbitration process is proving to be a promising course of action for out-of-network providers seeking to cure under-reimbursed surprise bill claims.
