June 02, 2017

State Legislation Addresses OutofNetwork Billing

Debate surrounding out-of-network provider charges continues in the states.

When trying to select a specialist provider who is part of their insurance network, patients sometimes discover that no qualified practitioner is available from their network. Insurance gaps often result in out-of-network providers submitting charges for services rendered.

Most providers seek in-network arrangements, but signing an in-network contract with insurers requires the physician to accept discounted payment in exchange for increased patient volume. In some case the discounts are so deep, the physician or his group must practice out-of-network to cover their expenses. Others are dropped from the in-network provider list without adequate notice or denied an opportunity to join the network entirely.

Although most stakeholders agree the problem of out-of-network billing is multi-faceted, disagreement revolves around devising fair solutions for all parties. Consequently, state legislation remedies vary in scope from bills seeking greater transparency to help avoid surprise bills, requiring network robustness, or solutions that address the high cost of out-of-network services.

Connecticut SB 426
An act concerning contracts between health carriers and health care providers, agents or vendors, participating provider directories and surprise bills. Its purpose is to (1) prohibit contracts between health carriers and health care providers or agents or vendors of health care providers, from proscribing disclosure of certain information, (2) require that health carriers maintain accurate, current and detailed preferred provider directories, and (3) restrict surprise bills for health care services.

Connecticut SB 451
An act protecting patients from unreasonable medical bills. Its purpose is to protect patients from unreasonable medical bills.

Hawaii SB 387
Requires a health carrier with a network plan to maintain a network that includes sufficient numbers of appropriate types of providers to ensure that covered persons have access to covered services. Specifies contract, disclosure, continuity of care and directory publication requirements.

Louisiana HB 435
Requires a healthcare facility disclose to a patient out-of-network providers and to provide for notice to insureds of possible balance billing at first registration with a health care facility. The bill also specifies penalties for failure to provide specified disclosure notices.

Nevada AB 382
Establishes provisions governing payment for the provision of emergency services and patient care to patients. As payment in full for the provision of emergency services and care, other than services and care provided to stabilize a patient, to certain patients a rate which does not exceed the greater of: (1) the average amount that the third party has negotiated with other hospitals in this State; or (2) 125% of the average amount paid by Medicare for the same or similar services in the same geographic area.