April 04, 2019

Nine States Consider Out-of-Network Billing Solutions

State legislatures are taking it upon themselves to find practical and politically feasible solutions to out-of-network billing. The emerging picture is mixed for radiologists, with most states still failing to recognize the role insurers and their narrow-network preferred provider organizations play in costly balance billing practices.

Surprise billing was a hot topic addressed by specific legislative proposals in Arkansas, Colorado, Georgia, Louisiana, Nevada, North Carolina, Texas, Washington State and Virginia this week.

In Arkansas, SB 512 would guarantee patients the right to receive reimbursement for any health care service, regardless of whether the health care provider is in- or out-of-network. The legislation passed both chambers and is awaiting the Governor’s signature.

In Colorado, SB 134, introduced in February, would set the reimbursement rate that the health insurance carrier must pay a health care facility if a covered person is treated for emergency services. The bill would also require in-network health care facilities and health care providers to inform insured patients about the terms of services from out-of-network providers. It would authorize arbitration for the payment of disputed health care claims if certain criteria are met. The bill is scheduled for a hearing at the Senate Health and Human Services Committee.

In Georgia, HB 540 has cleared both chambers. It would require hospitals to inform patients that providers might not participate with the same health benefit plans as the hospitals and that the patient should determine whether the physician is in-network. Hospitals would also be required to inform the patient that they may be responsible for non-participating providers’ fees if the provider is out-of-network.

Louisiana’s Rep. Kirk Talbot introduced HB 371. It would require payers to reimburse providers at least the Medicare rate. If providers are unhappy with the terms, they can file for arbitration. The arbitrator must then choose between the provider’s fees or the insurer’s payment for determining the fee for rendered services.

In Nevada, AB 469 was recently referred to the Assembly Committee on Health and Human Services. The bill would prohibit an out-of-network provider from charging a person covered by health insurance for emergency services that exceeds the copayment, coinsurance or deductible required by that policy. The bill would also require an out-of-network facility that provides emergency services to a covered person to: (1) notify the third party that provides coverage for the person that the person is receiving services at the facility and (2) transfer the covered person to an in-network facility no later than 24 hours after the person’s emergency medical condition is stabilized.

According to the bill, if the out-of-network provider had a previous contract as an in-network provider with the third party that provides coverage for the covered person within the 24 months preceding the emergency services to a covered person, the third party would be required to pay. The provider must accept a payment comparable to the estimate for those services under the most recent contract between the third party and the provider. If the provider does not accept the offer, the parties would proceed with arbitration.

In North Carolina, Sen. Ralph Hise introduced SB 386, a bill that would require a health care provider's total payment for out-of-network emergency care service to be equal to or greater than the benchmark amount of at least Medicare reimbursement rate for the same or similar services. For elective and emergency services, the legislation would also require facilities or health care providers to provide the insured with a detailed written disclosure on non-participating provider services and financial obligations as defined in the measure.

In Texas, HB 2967 and companion bill SB 1591 would mandate insurers to pay for covered services by an out-of-network provider at 80th percentile of all charges or at an agreed rate. The bills would also ban providers from charging people, insured through state-regulated health plans, for services received at an in-network facility above their out-of-pocket expenses as defined under the insurance coverage. If enacted, the insurer or out-of-network provider may initiate an arbitration process to determine the reimbursement amount for the health care service. The House version was referred to the Insurance Committee, and the Senate version was referred to the Business and Commerce Committee.

In Washington State, HB 1065, cleared the Senate Committee on Health & Long Term Care and is scheduled for a hearing at the Ways and Means Committee. The bill would require coverage billed at in-network rates for emergency services that screen and stabilize enrollees and would prohibit prior authorization. It would also prohibit balance billing directed to enrollees for elective services, including radiology, at in-network hospitals.

Virginia’s Gov. Ralph Northam proposed amendments to a revised HB 1700 which is scheduled for a vote in the House Appropriations Committee. Amendment No. 14 would mandate the Secretary of Health Human Resources to convene a workgroup to develop and propose a fair and equitable reimbursement rates for out-of-network emergency services.