The American College of Radiology (ACR) and other specialist physician organizations are establishing a framework to enable state lawmakers to solve health care billing problems associated with narrow network managed care in the wake of legislation adopted by four states in 2018 to address out-of-network care and balance billing.
Physician groups are stressing the need for policymakers to ensure that all health insurance companies provide adequate patient access to in-network physicians, including hospital-based and specialty physicians, through their plans. Measurable network adequacy standards that enhance patients’ ability to evaluate if they can gain ready access to in-network specialty care physicians at their in-network facilities are a first line of defense against out-of-network bills.
Transparency in out-of-network plan coverage is another important way to help patients navigate the health care landscape. They need accurate and up-to-date information from their plan’s facility and physician directories, as well as plan design details to determine their most cost-effective options for out-of-network specialty care.
Health care consumers often buy relatively more expensive preferred provider organization (PPO) plans under the assumption that they will cover, or minimize the need for, out-of-network specialty care. Coverage gaps in such plans are too often hidden or are inadequately disclosed until after the beneficiary receives care at an in-network facility that lacks the specialty in-network providers to meet their needs.
Complex balance billing reforms passed by legislatures in Maine, Missouri, New Hampshire and New Jersey in 2018 largely focused on either banning such billing practices or mitigating their high cost to consumers.
Maine’s new law uses “average in-network rates” as a minimum payment standard in exchange for a ban for unanticipated out-of-network care (excluding emergency care). New Hampshire now prohibits balance billing for pathology, anesthesiology, radiology and emergency services. The state also set minimum payment at “a commercially reasonable value.”
Missouri now bans balance billing for emergency care and requires a “reasonable reimbursement” while allowing for an arbitration process if the out-of-network physician declines the payer’s reimbursement offer.
New Jersey lawmakers prevented balance billing by out-of-network providers and establishes “baseball” (in or out) arbitration to resolve payment disputes. The law also allows self-funded employer ERISA health insurance plans to “opt-in.” Employers have an option to protect their employees from balance bills by opening themselves up to arbitration when a physician disputes his or her payment. However, if the employer does not opt-in, the patient is then offered an option participate in arbitration with the physician.
Looking forward to 2019, many state legislatures are expected to re-introduce balance billing proposals from previous years. The American College of Radiology is confident that out-of-network and surprise medical billing issues will be considered by several states in the months ahead. Draft legislative proposals are being circulated in Ohio and the state of Washington. Lawmakers in New Mexico, Nevada, Pennsylvania and Texas have held meetings to discuss the issue.
ACR members and its state affiliates are urged to monitor Statescape, a weekly feature of Advocacy in Action eNews, for continuous state-by-state coverage of balance billing legislation. Questions may be directed to Eugenia Brandt, the ACR’s director of state regulatory and association affairs, at firstname.lastname@example.org.