The Ohio Society of Pathologists (OSP) and the CAP asked the Ohio Department of Insurance to address a proposed regulation’s nonconformance to the state’s out-of-network law (HB 388). The CAP works with state pathology societies, like the OSP, to urge state regulators to ensure health plans maintain robust networks of physicians to ensure timely access to care for all insured patients.

Specifically, both groups highlighted that the draft rule incorrectly applied to clinical laboratory services provided by out-of-network providers when ordered by an in-network provider, unless the provider providing laboratory services discloses to the patient their network status before the services provided. The OSP and CAP noted that the statute, which goes into effect January 1, 2022, has no notification requirement, and expressed concerns of failing to require health plan transparency or disclosure of the payment methodology from the health plan issuer to the out-of-network provider. The Ohio State Medical Association (OSMA), OSP, and the CAP also urged that the state clarify the need for specification of payment violations by health plan issuers.

In July, the OSP, the OSMA, and the CAP conferred with the Ohio Department of Insurance staff to discuss detailed concerns of the regulatory draft comments and the implications of nonconformance to the law Act. The OSP and the CAP noted the impact of community-based (non-facility) out-of-network clinical laboratory referrals that are made by in-network providers to be mandated to provide patients with written notification requirements from the clinical laboratory, before performing service or subjection to the law’s balance billing ban. The requirement is contrary to the statute, which is expressly limited to only out-of-network clinical services provided at in-network facilities when patients do not have access to in-network providers. Unfortunately, the Ohio Department of Insurance, while initially receptive to the objection, failed to include revised changes in the second version of the draft rule on clinical laboratory services and other substantial concerns from other stakeholders.

The OSP and the CAP retained legal counsel to submit the regulatory comments, addressing the rule’s improper application to all out-of-network clinical laboratory services ordered by in-network providers. The Ohio Department of Insurance submitted the Business Impact Analysis to Ohio’s Common Sense Initiative, directly noting the proper purview of the Act, thereby strengthening the OSP and CAP’s position.

The CAP and OSP remain engaged in Ohio’s rulemaking process.