Majority of states lack laws to protect patients from balance billing

Most states do not have laws that protect patients from balance billing by an out-of-network physician for care delivered in an emergency department or in-network hospital, according to an analysis of laws in all 50 states and the District of Columbia by researchers at Georgetown University.

Balance billing occurs when patients treated by an out-of-network provider receive an unexpected bill for the difference between what the patient's health insurance paid and what the provider charged. Balance billing typically occurs after a patient has been rushed by ambulance during an emergency to an out-of-network facility for care or when a patient receives care at an in-network hospital by an out-of-network physician.

According to the researchers' analysis, only 21 states have direct statutory or regulatory protections in place to shield consumers from balance billing for care provided by out-of-network physicians in EDs or in-network hospitals.

However, some of those 21 states limit balance billing protections, which leave consumers at risk. For example, some states limit protections to certain types of managed care plans or to ED settings, according to the report.

The analysis revealed only six states — California, Connecticut, Florida, Illinois, Maryland and New York — have a comprehensive approach to guarding patients from balance billing.

"The fact that consumers are more likely to experience balance billing in situations where they have no control over which providers treat them suggests that additional state and federal policy solutions are needed to protect consumers fully and limit financial risk," wrote the researchers. "Yet comprehensive policy solutions have been elusive, largely because of disagreements between insurers and providers concerning the appropriate levels of payment for medical services."

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