finding policy solutions for provider directories and surprise medical bills
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Julie SilasFebruary 2, 2016
Finding Policy Solutions for Provider Directories and Surprise Medical Bills
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Who We Are – Consumers Union
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Among those respondents, more than one out of ten were charged an out-of-network rate when they thought the provider was in-network.
Received a surprise medical bill where their health plan paid less than expected (higher than the national avg)
1 in 10
Consumer Reports National Research Center – Survey fielded December 17, 2015 thru January 11, 2016
41%
Survey of 407 privately insured Georgia residents
Overall, the majority of Georgia privately insured residents assume doctors in an in-network hospital are in-network
66%
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• What are they?• In-network facility; out-of-network providers• ER docs, hospital “ologists”• After care, get the “surprise”
• What is the surprise?• Higher cost-sharing• Balance billing
Surprise Out-of-Network Medical Bills
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• How do they happen?
• Faulty provider directory• Emergency situation
• No opportunity or ability to choose
Surprise Out-of-Network Medical Bills
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“The uncertainty is stressful, because in addition to the constant billing errors having to be resolved, we must now also constantly be worried about any staff that comes by the hospital room because they might be secretly preparing an immense invoice. What recourse does anyone have in such situations currently – your options are to suddenly cease medical care, or be forced to pay exorbitant fees for routine procedures that should be covered under the insurance plan.”
– Kennesaw, GA
“I met the anesthesiologist while on the table, being prepped for surgery and, I must admit, did not think to ask him if he was in-network. Who would? I had to file some sort of protest but ended up only paying in-network charges.”
- Atlanta, GA
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“The specialist & ward (hospital) doctors were standing there, neither informed me that the specialist DID NOT accept my insurance. I later received a bill from the specialist for $6,000.00 for his 3-4 minutes of work.”
– Acworth, GA
“I argued with both Insurer and hospital that the very nature of an emergency visit necessitates an evaluation by an emergency physician, and that to say that an ER is ‘in-network’ is to imply that the physicians one sees as ER docs are also ‘in-network.’ My appeals were simply denied (twice) and my argument was not addressed. Eventually I was forced to pay the out-of-network fees.”
– Cartersville, GA
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• Very few state laws• 2/3 had no requirements for
how insurers update their directories*
• If addressed, often outdated solutions based on paper directories
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Blah blah
* NAIC 2014 survey of Insurance Commissioners
• ACA –addressed provider directories as part of network adequacy
• Recent federal changes provide stronger standards – but limited
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Blah blah
Provider Directory
• Federal Rules• All insurers provide direct links to online listing
• Updated monthly
• Machine-readable format
• State level• AZ and VT – update twice/year
• NY – update changes within 15 days• CA – weekly updates
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Blah blah
Provider Directory - GOALS
• Anyone can use directory• Accuracy – updated, and de-list if no
update• Robust consumer reporting (dedicated
line to report inaccuracies)• If rely on inaccurate directory = restitution• Public needs to understand criteria for
creating the network
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Blah blah
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• ACA emergency room rules = in-network cost-sharing, no protections against balance billing
• Proposed Federal Legislation (HR 3770) – rules tied to hospital Medicare payments
• State-based activity – ban on balance billing applies to insurers/providers• NY, CT, and MD = laws in place• At least 12 other states taking action
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Blah blah
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1 Accurate and up-to-date provider directory2 Disclosure of network status – whether in-
or out of network3 Ban on balance billing for out-of-network
surprise bills4 A well-defined process for determining
payment of surprise bills5 Consumer rights information
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Blah blah
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Thank you!
Please email Julie Silas with any questions:
Reports can be downloadedfrom: www.consumersunion.org