New Resource for Consumer Advocates on Out-of-Network Payment Disputes in Balance Billing Legislation

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State legislatures are gearing up for the 2020 legislative session. Thanks to a lack of action in the U.S. Congress in 2019, many of these legislatures will be considering state-level protections for consumers to prevent surprise out-of-network medical bills. These bills can occur when enrollees unknowingly or unexpectedly receive out-of-network care, typically in emergency situations or under the care of an out-of-network physician at an in-network facility. If the health plan does not cover this out-of-network care or pays only a portion of the charge, providers will often bill the patient for the balance. These “balance bills” can sometimes be in the thousands of dollars. Many proposed policies to protect people in these situations have bipartisan support, but disagreements between providers and insurers on how to settle payment disputes have stalled progress.

But as consumers continue to face unjustifiably high balance bills, states as diverse as Georgia, Maine, Oklahoma, Minnesota, Virginia, Pennsylvania, Kentucky, and others are considering action this year to protect consumers.* Just as with the federal legislation, however, one of the key sticking points for state policymakers will be how to approach out-of-network provider reimbursement.

With the help of CHIR experts, Community Catalyst recently published a new resource for state advocates and policymakers: The Advocate’s Guide to: Addressing Out-Of-Network Payment in Surprise Balance Billing Legislation. The latest addition to the health insurance reform toolkit provides background information about balance billing and outlines potential options for addressing provider payments, including payment standards, dispute resolution, and other approaches. The new guide also delves into considerations surrounding implementation, cost, and advocacy efforts.

You can access the entire health insurance reform toolkit here and read the new guide to balance billing payment standards here.

*Only federal law can establish balance billing protections that apply to self-funded employer-sponsored insurance.

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