More skirmishes from the provider network war

How could some of the proposed changes affect your customers? Read on.

The revised model could:

• Add a formal definition of “balance billing” — the practice of an out-of-network provider billing for the difference between the provider’s stated charge and the health plan issuer’s allowed amount.
• Add a definition of “emergency medical condition” that would include symptoms that would “lead a prudent layperson, possessing an average knowledge of medicine and health” to expect to suffer harms such as serious impairment of bodily functions, serious impairment of a bodily functions, or a threat to the safety of an unborn child.
• Add definitions of “telemedicine” and “ telehealth.”
• Expand the situations in which a plan would have to make out-of-network care available at in-network rates.
• Give enrollees who are undergoing “active treatment” the treat to continue to see their old providers when a health plan issuer terminates the providers’ contracts without cause.
• Set minimum provider directory standards, including standards for online directories.
• Increase the number of situations in which a plan issuer would have to tell regulators about network changes. In a drafting note, drafters have suggested that regulators might want to get warnings from issuers when material changes in provider reimbursement rates and enrollees’ out-of-pocket costs might affect the enrollees’ access to providers.

See also: 3 ways proposed PPACA risk program rules could trip you up