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Gopal & Jimenez Introduce Bill to Address Insurance Audits & Claims Payment for Health Care Providers During Pandemic

In an effort to ease the workload of health care providers overwhelmed by patients with COVID-19 during this pandemic, Senator Vin Gopal and Assemblywoman Angelica Jimenez sponsor identical bills in the Legislature to ease some of the usual administrative tasks required by health insurance companies and guarantee payment of certain medical claims. The legislation was introduced in the Assembly on Friday and the Senate on Monday.

Under the bill (A-4005/S-2431), health insurance audits and audit-related activities would be suspended during the current state of emergency and for 90 days after its conclusion. As such, Medicaid and other health insurers in the state would not be permitted to audit providers on medical necessity of services, level of care, diagnostic coding and more.

The purpose of the legislation is to make it easier for hospital employees overwhelmed with large numbers of COVID-19 cases to provide care to their patients without setting aside time for administrative paperwork and audits normally required by health insurers.

“Right now, thousands of patients and families are struggling to care for sick relatives and loved ones, at a time when hospitals are also struggling to keep enough staff to care for a sudden flood of coronavirus-positive patients,” said Senator Gopal (D-Long Branch). “It’s unreasonable and inhumane to expect these families and hospitals to spend precious resources dealing with bureaucratic paperwork and expensive insurance denials when our state is pulling out all the stops to stop this virus.”

The bill also requires health insurers to suspend administrative and technical denials of claims during the state of emergency. It further mandates that claims cannot be retroactively denied for medically necessary services related to COVID-19 or any emergency department and inpatient services provided by hospitals during the state of emergency.

“Healthcare providers are busier than ever in the midst of this pandemic,” said Assemblywoman Jimenez (D-Bergen, Hudson). “With the ongoing efforts to combat the spread of a dangerous new illness and save the lives of the thousands of residents hospitalized with COVID-19, these hard-working professionals don’t have time for audits. They need to be able to provide the care patients need when they need it, without worrying about completing additional paperwork or having a claim denied.”

“When this state of emergency comes to an end, we can’t let patients go broke just because a treatment they thought was lifesaving didn’t meet an insurance company’s standards in combating COVID-19,” said Gopal. “We need all hands on deck, which means that we can’t afford to play by the normal rules of bureaucracy and business-as-usual. If someone is sick, their insurance company needs to pay for their treatment – with no excuses.”

Several organizations are in support of the bill, including the New Jersey Hospital Association (NJHA) and the Medical Society of New Jersey (MSNJ).

“Our healthcare providers and their teams have been on the front lines during this COVID-19 crisis in providing quality care to our patients, both COVID and non-COVID alike,” said NJHA Vice President of Government Relations and Policy Neil Eicher. “They’ve delivered the care; now we need health insurance companies to ensure they’re providing the coverage and prompt payments to our providers, without unnecessary denials and audits for services provided to patients during this crisis. We thank the sponsors for their leadership on this issue.”

“The COVID-19 pandemic has posed several challenges to physicians throughout New Jersey, as they have needed to adjust their practices and operations accordingly to provide the highest quality of care while battling on the frontlines of this crisis,” said MSNJ CEO Larry Downs, Esq. “During these uncertain times, having measures like this in place will ensure that physicians may keep their focus solely on providing the most timely, optimal care to their patients while not being burdened with impeding administrative tasks.”

Both sponsors are committed to working with relevant parties, including health insurers, in order to advance the fair and responsible legislation.