February 19, 2016

State Legislations Propose Limits on Balance Billing

California, Florida, Georgia, Hawaii, Kentucky, Maryland, New Hampshire, New Jersey and Washington are considering legislation that would regulate out of network charges, price transparency, and network adequacy to limit balance billing practices by out-of-network providers.

The bills propose limiting the providers’ ability to bill patients for services rendered by an out-of-network health care provider when they were treated in an in-network facility. Such situations arise most often for anesthesiology, pathology, radiology, surgery and emergency room services.

The legislative proposals range from requiring patient informed consent to receive services from out-of-network providers in non-emergency settings to limiting out-of-network health providers from charging carriers more than a certain percent of the specified Medicare rate for comparable services. Along the same lines, some bills seek to eliminate the practice of balance billing by promoting transparency in health care fees and requiring health care providers to submit estimated charges to patients prior to performing specified services.

Supporters of such legislation argue that managed care patients face the greatest risk of extraordinarily expensive charges for out-of-network services when their preferred provider organization (PPO) offers limited options for where they may receive health services or when the PPO supplies its members with inadequate information about the limited extent of provider participation and status.

Although a few out-of-network physicians may charge excessive fees, most physicians agree that deliberately narrow networks and predatory contracting practices by health plans leave patients and providers at a disadvantage. Some patients are driven to purchase insurance products that are incapable of assembling an adequate provider network to serve their essential health care needs.

To remedy balance billing, physicians overwhelmingly favor putting in place fair contracting provisions and benchmarking fee proposals against claims data collected by an independent, unbiased, non-profit entity, such as New York State’s Fair Health or billing standards based on “usual and customary” charges. Legislation proposing such remedies are likely to gain prominence as the 2016 state legislative sessions move along.