In an effort to promote transparency on price, cost and billing for Consumers Administration’s FY 2017 budget calls to “eliminate surprise out-of-network health care charges for privately insured patients” and to “develop uniform and transparent consumer health care bills.” (source: Table S–9 of Mandatory and Receipt Proposals)
U.S. Department of Health and Human Services (HHS) convened a roundtable of stakeholders in an effort to identify efforts already underway to protect patients from surprise charges. The administration’s proposal set a goal of protecting consumers from surprise bills when services are performed by a non-participating (out-of-network) provider at a participating hospital/ambulatory surgical center or when a participating physician refers an insured patient to a non-participating provider.
The health care provider community argues that the recurring problem is best described as a surprise lack of coverage within a network that may be deemed inadequate or too narrow to service the population needs effectively. The use of narrow provider networks in health insurance plans is an effective cost containment strategy and use of narrow networks will continue in the future. Although network design features differ among plans, insurers are able to offer lower premiums by limiting the number of providers available to plan enrollees.
One of the important points noted was that an overwhelming majority of health care providers are offering their services as in-network providers; however, all present agreed that the issue is problematic for the consumers and calls for a more in-depth discussion for solutions. Discussion centered on pros and cons of existing state legislation addressing out-of-network billing as well as need for development and use of standardized terminology when discussing health care benefit specifics (co-pay/co-insurance/deductibles/out-of-pocket maximums).
During the discussion, the stakeholders have highlighted the following areas for further discussion: collection of factual data on out-of-network charges that occur, a review of technical solutions currently offered to consumers for estimates of charges and coverage, development of standardized terminology to describe health care insurance products, a recommendation for increased oversight and enforcement of network adequacy standards at the state level (particularly a closer examination of the number of in-network hospital based providers within in-network facilities), and a review of resources available to state regulatory agencies charged with enforcement.
The roundtable was a first step in what the HHS staff hopes to be a productive collaboration between providers, health insurers and consumer advocates.