2 state options to eliminate surprise out-of-network billing


A recent white paper spotlights two state options to protect patients from surprise out-of-network billing.

The white paper was written as part of a partnership between the Center for Health Policy at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics, the USC-Brookings Schaeffer Initiative for Health Policy.

The first state option is a billing regulation approach. States using it would:

  • Limit out-of-network charges. This limit would be equal to a multiple of the relevant Medicare rate "in line with what nonemergency or ancillary specialists with similar training are paid by commercial payers," the authors write.
  • Require fully insured health plans to not put beneficiaries on the hook for cost-sharing beyond normal in-network cost-sharing amounts for out-of-network services
  • Apply these rules to out-of-network emergency services as well as out-of-network ancillary clinician, hospitalist and neonatology services delivered at an in-network facility

The second state option from the white paper is a hybrid billing regulation/contracting regulation approach. Under this option, states would implement the billing regulation approach for out-of-network ambulance services and emergency services delivered at an out-of-network facility.

States using the hybrid approach also would prohibit independent billing for emergency, ancillary clinician, hospitalist and neonatology services delivered at in-network facilities. 

"By enacting either of these approaches, states could largely protect all privately-insured state residents from surprise out-of-network bills, regardless of whether they are enrolled in a fully- or self-insured health plan," the authors concluded.

"And by eliminating the lucrative out-of-network billing option for ED [emergency department] and ancillary physicians, these approaches could also reduce healthcare spending and insurance premiums," the authors said.


More articles on healthcare finance: 

US health spending estimated to reach nearly $6 trillion in 8 years
National healthcare groups outline surprise-billing principles
California proposed health-pricing transparency bill would affect Kaiser Permanente

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