State legislators are trying to push for some bottom-up health finance reform: Protecting insured patients from unpleasant hospital physician billing surprises.
The National Conference of Insurance Legislators, Troy, N.Y., has posted a draft of a proposal that would create a model for imposing balancing-billing disclosure rules on health plans, on the doctors who practice in hospitals and other health care facilities, and health care facilities.
Health maintenance organizations and preferred provider organizations usually negotiate provider contracts that require in-network providers to accept pre-negotiated fees as the full price for in-network, properly approved medical services.
If Mrs. Jane Jones gets the proper approvals to see Dr. Smith, an in-network neurosurgeon, for an initial exam, for example, Dr. Smith can bill Mrs. Jones only for the pre-negotiated price of an initial exam.
Mrs. Jones must make any required co-payments and coinsurance payments, but Dr. Sam Smith cannot bill her for the difference, or balance, between his usual price for an initial exam and the price he negotiated with Mrs. Jones' health insurer.
If Mrs. Jones goes to an in-network hospital for preapproved brain surgery, and Dr. Smith performs the surgery, the hospital and Dr. Smith must accept the health insurer's prenegotiated prices. But, if Dr. Debbie Doe, an out-of-network anesthesiologist, assists, Dr. Doe can bill Mrs. Jones for the balance left over when the health insurer pays Dr. Doe what it thinks she ought to be paid.
The NCOIL draft model would continue to permit out-of-network doctors to balance bill patients.
But health plans would have to warn enrollees about balance billing in enrollment and renewal materials; on explanation of benefits notices; and on plan websites.
A health care facility would have have to provide "a conspicuous written disclosure to a consumer at the time the consumer is first admitted to the facility."
The notice would have to inform the consumer that some physicians in the facility might be out-of-network and might bill the consumer for amounts not paid by the consumer's insurer.
Physicians would have to tell patients in billing statements that are out-of-network and provide a telephone number that patients could use to work out alternative payment arrangements.
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