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Friday, 10 May 2019 11:27

Not All Surprises are Good

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Over the past year, Fall River has seen an increase in a provider practice called “surprise medical billing” or “balance-billing.” Out-of-network providers will bill the patient even though they were seen at an in-network hospital and had no choice in who they were treated by. We have been anxiously awaiting legislation that would better-protect patients, and in early May Colorado lawmakers passed the Out-of-network Healthcare Services bill to address this issue.

This bipartisan bill, House Bill 19-1174, which is now headed to the Governor’s desk, prohibits healthcare providers from sending patients a balance-bill when they have unknowingly received out-of-network care. It also sets a reimbursement rate that insurers pay to out-of-network providers. 

Specifically, the bill:

  • Requires health insurance carriers, providers, and facilities to provide patients with information regarding the services of out-of-network providers and in-network and out-of-network facilities;

  • Outlines disclosure requirements and the claims and payment process for out-of-network services;

  • Requires several entities such as the insurance commissioner and others to publish requirements for consumer disclosures, including the timing, format, contents, and language;

  • Establishes the carriers’ reimbursement amount for out-of-network providers providing services at in-network facilities and emergency facilities;

  • Creates a penalty for out-of-network providers who fail to comply with the payment requirements; and

  • Reserves money from the general fund to the department of public health and environment, and from the division of insurance cash fund to the division of insurance.

Before this bill, Colorado was among several states that had previously passed different levels of hold harmless protections when it comes to surprise medical billing. Indicated on a map, Colorado has had “partial protections” against balance-billing, which allow the patient to be held harmless from paying a balance-bill for an out-of-network provider at an in-network facility. The problem has been that consumers are largely unaware of this protection. Even worse, nothing stopped the out-of-network provider from sending a bill, or even placing the member in collections or taking a lien out on their mortgage.

This new measure should bump Colorado from the 25-state group with “partial protections” into a group of 10 states with “comprehensive protections.” The measure will protect a good chunk of Coloradans, but it may not apply to certain insurance plans, such as self-funded plans not governed by state law. https://www.kunc.org/post/colorado-join-other-states-increased-consumer-protection-against-surprise-medical-bills#stream/0

On a national level, there are some federal bills in the early stages of introduction to the House and Senate that address balance-billing. https://www.nbcnews.com/politics/congress/dem-gop-senators-say-they-have-fix-surprise-medical-bills-n1006056

If you or your employees are experiencing an escalated claim concern, please reach out to your Fall River Client Manager for help.

Read 232 times Last modified on Wednesday, 22 May 2019 14:34
Juliet Fitzgibbons

Juliet joins Fall River as an Account Executive and brings over 15 years of prior broker and account management experience. Her experience brings extensive knowledge on employee benefit programs, account management and creative cost-saving strategies and compliance solutions for employers of various sizes.

She is responsible for new business proposals, client renewals including plan benchmarking, rate analysis and mid-year reviews. She helps clients navigate healthcare systems and educates employers and employees through open enrollment meetings and day-to-day service requests. Juliet joined Fall River in 2015.