States fight out-of-network bill surprise problem

Use of narrower provider networks to hold down health coverage costs may be drawing regulators’ attention to a related issue: Providers who surprise patients who wanted in-network care with big out-of-network bills.

“Balance billing” often crops up when patients go to in-network hospitals, and then get care from out-of-network radiologists, out-of-network pathologists, or other out-of-network specialists.

In-network providers have usually agreed to accept an insurer’s negotiated reimbursement rates, and to take up any disputes over billing with the insurer, rather than trying to bill the patient for the balance.

Out-of-network providers have no contractual obligation to accept an insurer’s reimbursement rate, and they may try to bill the patients for part all of the balance.

Insurers and agent groups have been talking about the balancing billing problem for years, but usually losing in head-to-head battles with health care provider groups.

Lynn Quincy, a representative from Consumers Union, gave a briefing on the topic Sunday, in Phoenix, at the spring meeting of the National Association of Insurance Commissioners (NAIC). She appeared at a session organized by the NAIC/Consumer Liaison Committee.

The NAIC has appointed the liaisons on the committee, who come from organizations such as California’s Office of the Patient Advocate, Virginia Organizing, and Autism Speaks, to speak for consumers in NAIC proceedings.