May 2019 ~

A recent report from American College of Radiology, shows a trend in the United States as 14 more states introduce legislation designed to emphasize consumer protections and expanded mandated access to screening exams in bills potentially affecting medical imaging.

These scope of practice legislations would allow physician assistants, physical therapists or advanced practice nurses to order imaging exams and, according to the report, an increasing number of states are considering or adopting mandates for breast density disclosure, expanded mammography benefits, mechanisms to address or mediate payments for out-of-network health care services, and expanded scope of imaging practice.

Breast Density

In Oklahoma, SB 443  cleared both chambers and, if put into law, would require health care facilities to send summaries of mammography reports by electronic mail upon request.

If the facility determines that a patient has heterogeneously or extremely dense breast tissue, the summary of the mammography report shall include the following notice:

“Your mammogram indicates that you have dense breast tissue. Dense breast tissue is common and is found in more than fifty percent (50%) of women and is not abnormal. However, dense breast tissue may make it more difficult to detect breast cancer and may be associated with an increased risk of breast cancer. This information is being provided to raise your awareness and to encourage you and your health care provider to discuss this and other breast cancer risk factors. Together, you and your health care provider can decide if additional screening options may be right for you. A report of your results was sent to your health care provider.”

Breast Tomosynthesis

In Colorado, HB 1301 has been introduced in an attempt to mandate coverage for preventive breast cancer screening studies defined as: a mammogram for individuals at average risk, a mammogram using a noninvasive imaging modality as recommended by the health provider or a mammogram and medically recommended subsequent noninvasive imaging modality for patients at average risk with incomplete mammogram results or for high-risk patients. The bill would also mandate coverage for annual breast cancer screenings for all individuals who have at least one of the following breast cancer risk factors: prior family history, 40 years or older or an increased lifetime risk determined by a risk factor model. If finalized, would cover any cost-sharing expenses for any noninvasive imaging modality recommended by the health provider.

In Hawaii, SB 1034 was recently passed by the state House and seeks to amend the existing health insurance mandate to specify that coverage of low-dose mammography includes coverage for digital mammography and breast tomosynthesis.

Cancer Screening

In Connecticut, proposed bills HB 7124  and SB 838 each seek to provide coverage for mammograms or digital breast tomosynthesis (DBT) for women ages 30 or older. The proposals would cover annual mammograms when recommended by a physician if the patient has a family or personal history with breast cancer or if the patient has a prior history of breast disease. If passed, additional provisions would provide coverage for ultrasound screenings if a mammogram demonstrates heterogeneous or dense breast tissue or if the patient is deemed to be at high risk for breast cancer.

In Illinois, SB 162  hopes to expand coverage to diagnostic mammograms when deemed medically necessary and would cover breast ultrasounds for evaluating dense breast tissue.

Certificate of Need

In Alaska, SB 1 proposal seeks to repeal the certificate of need program for health care facilities. The bill cleared the Senate Health and Social Services Committee and was referred to the Finance Committee.

Out-of-Network Billing

Alabama’s HB 11 legislation proposal would require hospitals to seek reimbursement directly from the patient’s health insurer, except for copayments and deductibles.

In Colorado, HB 1174, if approved, would require health insurance carriers, health care providers and health care facilities to inform enrollees about services by out-of-network providers and in-network and out-of-network facilities. The bill would establish the reimbursement amount for out-of-network providers that provide health care services to covered persons at an in-network facility and for out-of-network providers or facilities that provide emergency services to covered persons.

Missouri’s HB 756 proposal has been designed to mandate health care providers to send any claim for out-of-network charges to the insurer within 180 days of out-of-network care. If enacted, reimbursements not agreed to between the two parties would require arbitration wherein the arbitrator would determine an amount between 120 percent of the Medicare allowed amount and 70th percentile of the usual and customary rate for unanticipated out-of-network care.

New Mexico recently signed its SB 337 legislation into law which will require health insurers to reimburse out-of-network providers and will not require prior authorization for emergency care. Patients will not be responsible for charges and fees for covered elective services by out-of-network providers if participating providers are unavailable at an in-network facility. Insurers will reimburse out-of-network providers at 60th percentile of the allowed commercial reimbursement rate for the particular health care service in the same or similar specialty in the same geographic area and no less than 150 percent of the Medicare rate.

Scope of Practice

In California, the SB 697 bill seeks to expand the scope of practice of physician assistants (PAs) to include ordering, performing and interpreting diagnostic studies and therapeutic procedures. If enacted, PAs would also be allowed to supervise therapeutic and diagnostic measures for licensed or unlicensed personnel. The bill is scheduled for a hearing on April 22.

Florida’s HB 821 legislation, if approved, would expand the scope of advanced practice registered nurses by allowing them to order diagnostic tests.

North Dakota recently approved HB 1175 which allows PAs to order and evaluate a diagnostic study and therapeutic procedures and introduced SB 774 in hopes of expanding the definition of physical therapy to include ordering diagnostic imaging and studies.

And in South Carolina, the state’s SB 132 bill seeks to expand the scope of PAs to include ordering diagnostic, therapeutic and other medical services.

Source(s): RBMA Washington Insider for April 15, 2019; American College of Radiology;