As the price of healthcare rises and the reach of its coverage erodes, legislation around balance billing---the process by which patients receive higher-than-expected bills from healthcare providers, often due to having unknowingly received out-of-network care---has become a bellwether in state capitols across the U.S.

States Have Solidified Core Issues

So far, five states have enacted laws to protect against or prohibit balance billing practices, including Illinois, California, Connecticut, Florida and New York. The most recent batch of successful state legislation has managed to boil the issues down to some combination of:

  1. Limiting charges for care delivered out of network (CA AB1305, CT SB433, FL HB221, UT SB216)
  2. Increasing network transparency and patient disclosures of potential costs (CT SB433, FL HB221, FL HB1175, GA SB302, MN HF3142, TXSB425)
  3. Analyzing the potential parameters for balance billing (GA SR974)
  4. Establishing processes to resolve billing disputes between patients, doctors, and hospitals (FL HB221, TX SB481)

Failure has not Weakened Lawmakers' Resolve

At least to some extent, the blueprint of passed state legislation on balance billing is inspiring other states to introduce similar bills, or at least commit to further exploring the issue. Persistence and willingness to compromise has been key to getting bills signed into effective laws. Even in states where bills die in committee, expire without a vote in session, or fail to gain traction for other reasons, Senators and Representatives appear committed to negotiating, re-examining and re-submitting draft bills to improve chances of success. The reasons are several and powerful:  vocal, voting, media-savvy constituents have aired a steady stream of viral, emotionally fraught pleas (often on social media) for relief on the issue, insurance companies are supportive of these bills for their own reasons, and the bills themselves generally have bi-partisan support from everyone, save the physician lobby.

No doubt, it will take persistence to sort out the sticking points that have caused some state bills to fail or “time out.” These have mainly centered on how, exactly, to create a clear formula and methodology for cost-sharing. Beyond that, most people on both sides of the aisle do agree that there is a need for more transparency, some set of parameters around balance billing, a means of dispute resolution, and more research on the problem and viable, equitable solutions that do not economically debilitate consumers, doctors, hospitals and insurance companies.

States to Watch in 2017

Arizona — SB1441

In instances where it was unclear whether a medical provider was in-network, patients would be able to appeal surprise bills through the Department of Insurance, which would set up a phone conference involving the doctor, insurance company and the patient, with the objective of arriving at a mutually agreed upon settlement.  

Georgia — HB71, SB8

Both bills would protect Georgia consumers from surprise out-of-network medical bills, and would require better transparency, stopping short of requiring hospitals to disclose which doctors on the patient journey would be considered in-network.  HB 71 passed out of the House Insurance Committee but did not receive a vote from the full House before the Crossover Day deadline. SB 8 passed the full Senate.  A substitute to SB 8 passed out of the House Insurance Committee and passed out of the House Rules Committee on March 22nd. SB 8 did not receive a vote from the full House before the end of the Legislative Session.  Instead, House Resolution 745 passed.  This resolution creates a study committee that will convene to examine the issue of unexpected out-of-network medical bills in the 2017 off-session.

Ohio — SB284

The bill would require hospitals to provide two written notices to insured individuals, clarifying whether the hospital or physician is an in-network provider, and estimating any potential out-of-network fees for the scheduled service. It would also require informed consent from the individual seeking services from an out-of-network hospital or provider at least 24 hours in advance of the service. Absent consent, the bill would prohibit providers from charging more than what that individual would have paid had the provider been in-network. In emergencies, patients could not be charged more than the in-network cost of a service.

Oklahoma — HB 2216

This bill, which aims to lessen surprise medical bills, passed out of the Oklahoma House of Representatives with a unanimous vote of 93 to 0. The bill requires a non-contracted provider to give a health plan enrollee notice, a good-faith estimate of charges and a disclosure that the provider will either accept the assignment of benefits for the plan’s allowed amount or balance-bill the enrollee. Patients will be able to request a different provider who is covered by insurance. In emergencies, hospitals must notify patients of the network status of treating medical personnel as soon as s/he is stable. The bill is now with the OK Senate for consideration.

Oregon — HB 2339

If passed, this legislation would would require insurers to reimburse non-participating providers at a “reasonable and customary” rate, and would prohibit health care provider or participating health care facility from balance billing a patient covered by health benefit plan or health care service contract for services provided at participating health care facility.

Pennsylvania — SB1158

The Emergency Medical and Health Care Services Surprise Billing Prevention Act, which recently died in the Banking & Insurance Committee, would have altogether removed the patient from billing disputes, and required insurers and healthcare providers to settle involuntary out-of-network bills through arbitration.  Sponsoring senators intend to re-introduce the bill in future sessions.

Rhode Island — HB5012

Although it died in committee, this bill is slated for re-vamp and re-introduction. Had it passed, the so-called Craven Bill would have required the establishment of a dispute resolution for bills for emergency care, and surprise medical bills for out-of-network service.

Texas — SB507

This bill would require clear notices on balance bills to explain to patients their eligibility for mediation. Bills from all types of out-of-network providers treating patients at in-network hospitals and other facilities would be eligible for state mediation, including bills from freestanding emergency rooms.

Utah — HB395
The original intent of this bill was to address balance billing in the emergency room setting. Had it passed, it would have used a national benchmark for typical charges to limit what hospitals and doctors can charge. Right now, that difference is unlimited. There are plans to shortly re-introduce a modified version of this bill in the Utah House of Representatives.

insideARM Perspective

Whether these proposed bills ultimately become law in their current form or not, the work of trial and error is well under way. It's clear that most state law makers will need to grapple with balance billing and its related issues, whether it's in this legislative session or the next.

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