The march toward more state remedies for out-of-network (OON) billing continued this week with steps by Michigan and Pennsylvania legislatures to consider proposals to protect health care consumers from OON bills.
In Michigan, the Senate Committee on Insurance and Banking was scheduled to hear testimony on S 570, which defines allowable terms for OON emergency services, and S 572, which bans OON providers from billing enrollees for elective services without their written consent.
S 570 would require out-of-network emergency medical personnel who provide a covered emergency service to be reimbursed at 125% of the amount covered by Medicare for the service, excluding any in-network coinsurance, copayments or deductibles. An out-of-network provider of an emergency service or of an elective service would not collect from the enrollee, directly or indirectly, any excess amount other than applicable coinsurance, copayments or deductibles. Providers may be fined for attempting to collect from the enrollee.
S 572 features the following requirements for billing enrollees from OON elective services:
• The enrollee would have to consent in writing at least 24 hours in advance of the service
• The consent could not be obtained at the time of admission or when the enrollee is being prepared for a procedure
• The enrollee would be given a written estimate of the cost of the services
• The consent would advise the enrollee that he or she may seek care from an in-network provider or contact the health plan issuer to find an in-network provider.
The consent form would require a notice with the language: “Your health benefit plan may or may not provide coverage for all of the services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan. We have conducted a good-faith search to determine whether your health benefit plan provides coverage for these services, and if so, to order these services from a provider that participates with your health benefit plan. You have a right to request that the services be performed by a provider that participates with your health benefit plan.”
S 572 also authorizes administrative fines for providers who do not obtain the required written consents.
In Pennsylvania, Rep. Tina Pickett introduced H 1862. The bill would reimburse out-of-network providers for a covered service at the commercially reasonable rate for that service. That rate would be the median, in-network, contracted rate under the applicable policy that the issuer would pay to an in-network provider minus the in-network cost sharing for the service. It would prohibit out-of-network providers from billing enrollees for the difference between the provider’s charge and the amount of the commercially reasonable rate paid by the issuer for the service. In the event of a dispute, an arbitration process would be administered by the American Arbitration Association under its Healthcare Payor Provider Arbitration Rules.
The bill was held for a second consideration before the House.