Week In Washington: Out of Network Bills

September 21, 2018

Out of Network Bills

Surprise balanced billing is quickly becoming one of the hottest health policy topics. Surprise balanced billing is when “patients cannot avoid being treated by providers outside their health plan’s contracted network”. The end result of such of an experience is that patients can see very high bills for which they were personally responsible, even if they weren’t aware (or sometimes conscious) when the choice is mad. While it’s often thought of a problem only for emergency department procedures, researchers have uncovered that the problem is more widespread that initially thought. Loren Adler et al’s research have found that 9% of elective inpatient care procedures can lead to surprise out of network bills. The research also found that currently that ED visits which can lead to surprise bills over 20% of the time. Given the scope of the problem, state and federal policy makers have started to tackle the issue.

New Jersey- New Jersey recently passed a new law requiring providers to inform patients if they are out of network, provide expected costs of the service and disclosures of patient’s financial responsibility. The bill also provides some requirements on emergency services and arbitration procedures. California also recently passed a bill that improves transparency for potential surprise billing and limits their cost to consumers. At least five other states are reviewing the issue or considering actions of this topic.


US Senate

Given the saliency of the issue, a group of bipartisan Senator’s will be rolling out their own surprise billing plan. The bill would also require providers to give notification to patients who receive emergency care at an out-of-network facility before they receive any nonemergency care. More significantly the bill would

• Cap patient’s liability at in-network cost-sharing amounts

• Requires health plan to pay out of network provider 125% of the average in-network rate

• Bans balance billing

If implemented the result of the bill would be that patients would have far less potential liability. The bill is in its infancy so there’s currently no timeline for potential passage.


Other News and Notes

Life InsuranceJohn Hancock announced it would no longer be underwriting traditional life insurance and instead will only offer policies that include the requirement of wearing trackable fitness devices.

Short Term Plans- The Association of Community Affiliated Plans (ACAP) and other interest groups sued the Federal government to stop the implementation of the short term duration policy. The other key regulatory change of the Trump Administration aimed to provide non-ACA plan choices to individuals, the association health plan expansion, is also currently being sued.