How states are dealing with surprise billing


To address "surprise" billing, states should focus on healthcare price transparency and insurance coverage, according to a post published by Forbes.

The post — written by Louis J. Goodman, PhD, executive vice president and CEO of the Texas Medical Association and a board member of the Physicians Foundation — outlined how states are dealing with the problem.

Four takeaways:

1. Surprise billing, also known as balance billing, can occur when a patient receives care at an out-of-network hospital or from an out-of-network provider at an in-network facility. The patient receives a possibly unexpected bill indicating they are on the hook for the difference between the provider's charge and the insurer's allowable amount. Dr. Goodman said patients increasingly are at risk of surprise bills as insurers narrow their networks to cut costs.

2. States have implemented measures to address and end surprise billing. New York has a law that prohibits providers from balance billing for emergency care. Texas legislation requires freestanding emergency rooms to post notice of any insurance networks they're part of and expands mediation protections for patients with preferred provider organization plans to all out-of-network emergency providers.

3. Some states prohibit out-of-network bills for nonemergency services as well, according to Dr. Goodman. He argued this "rewards the insurance company that is likely offering an inadequate contract while punishing the physician for refusing to accept an insurers' deeply discounted rate. In this way, a ban incentivizes the insurance companies to have narrow emergency care networks, which alleviates their accountability to pay for care."

4. Dr. Goodman said states should aim to answer these four questions to address surprise billing: "Is the physician or provider in-network?; What is the price for the services rendered?; What will the insurer's responsibility be, and what will it require the patient to pay?; What amount will the provider be paid for the services rendered?"

Read the full post here.


More articles on healthcare finance:

Patient leakage costs nearly half of healthcare organizations 10% of annual revenue, survey finds
Student resource website ranks top college programs for medical billing and coding
Frustrated by billing, patients are skipping routine healthcare

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