Continuing the trend of steadily increasing attention to the issue of balance billing, 2018 has wasted no time kicking off activity to move the needle in the direction of more comprehensive state legislation. Balance billing is the process by which patients receive higher-than-expected bills from healthcare providers, often due to having unknowingly received out-of-network care. Physicians' lobbies, state-level insurance departments, and state politicians have begun what is sure to be a year full of activity. 

Physicians weigh in

Recently, Physicians for Fair Coverage (PFC), a coalition of physician working on policy issues including balance billing, has weighed in on the balance billing issue by advocating that consumers be kept out of the issue between insurers and physicians. PFC recommends an appropriate and fair standard for out-of-network services using a reimbursement schedule connected to an independently recognized and verified charge-based database. To benchmark physician fees, PFC recommends FAIR Health, which it says maintains the largest collection of private insurance claims in the United States.

According to its website, PFC is actively working on state-level efforts around balance billing, and supports legislative efforts that would require:

  • A minimum benefit standard for out-of-network care with transparent, predictable and fair pricing for medical services so patients aren’t surprised about their health insurance coverage.
  • An adequate number of doctors and clinicians in health plan networks, especially in the emergency department, to serve the number of patients in that network.
  • In-network rates for patients who encounter unexpected out-of-network care.
  • Protections for patients so they are removed from payment disputes between clinicians and insurance companies.
  • A mediation process that a patient or clinician can initiate with resolution within 30 days.
  • Requirements to prevent insurers from providing false, misleading or confusing information.
  • Strong penalties for insurers and clinicians who violate the patient coverage protections in the law.

The group has even created model legislation based on successful bills passed in states like New York, and is monitoring legislation that seeks to correct the gaps in consumer protection at the state level.

More states tackle balance billing

As insideARM has recently reportedthere is still a lack of balance billing legislation in many states. However, legislative bodies in at least two states -- New Hampshire and Washington -- have kicked off 2018 with efforts to relieve the burden of balance billing.

New Hampshire is considering two bills this year related to balance billing. HB 1643 and HB 1809 focus on balance billing when a patient goes to an in-network facility but receives treatment from an out-of-network doctor, but only apply to anesthesiology, radiology, emergency medicine, or pathology services. The bills have so far won the support of the New Hampshire Insurance Department. Opponents of of the two bills argue that the problem won’t be solved with balance billing legislation, but instead must be solved as part of expanding New Hampshire’s inadequate health insurance network. In 2014, New Hampshire’s health insurance exchange launched with just one narrow-network plan.

In Washington, House Bill 2114 was reintroduced in January, and is winding its way through the House Rules Committee. If passed, it would require facilities, providers and insurers to disclose their network status. The legislation also allows for arbitration and mediation when disputes arise, and addresses the issue of consumers being charged for out-of-network providers staffing the emergency department, where most people have no control over who provides their care.

Despite the recent proposed bills in Washington and New Hampshire, there has been little progress at the state level in passing comprehensive balance billing laws. Last summer, the Commonwealth Fund published a helpful grid showing each state's current status regarding balance billing legislation; not much has changed since then. This round-up is helpful in that it details the elements of state laws currently in place, and shows features of state protections in direct comparison to one another:


Source of data:  K. Lucia, J. Hoadley, and A. Williams, Balance Billing by Health Care Providers: Assessing Consumer Protections Across States, The Commonwealth Fund, June 2017.

insideARM will continue to monitor the balance billing issue, including how hospital revenue cycle executives and physician practices are doing their part to cope operationally period of great flux, as the entire healthcare community faces the fallout of unpaid out-of-pocket medical bills.

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