Out-of-Network Payments

In 2017, "Surprise Billing" legislation was ultimately approved by the Legislature and signed by the Governor ended up having only a nominal effect on our Emergency Department Physicians as it covered only those cases where the billing in question was for over $1,000. 

C.R.S. 10-16-704 passed in 2019 capped OON reimbursement at the greater of 110% of the carrier's median in-network rate or the 60th percentile of the APCD.

Ban on balance billing with state IDR process for disputes. If a physician is OON, the insurer is supposed to pay the physician’s usual and customary provider’s charges (which should induce negotiated contracts to be in-network).

The current state IDR process is broken; insurers are "opting out" of participation. This leaves only the courts as a remedy for bad payer behavior. 2024 legislative efforts to make insurer participation compulsory if an IDR claim is pursued. This has stalled and will likely not pass in 2024 but legislative sponsors indicate they will bring this back in 2025.

Other Resources

Committee Substitute for Committee Substitute for Committee Substitute for House Bill No. 221 (2016 law on Out of Network and process to appeal)

State regulated Surprise Medical Billing legislation (HB888) passed and in effect 1/1/2021. Network Adequacy legislation (SB20) passed and in effect 1/1/2024.

Out-of-network payment – MACEP joins the Mass Medical Society and the Mass Hospital Association in support for the federal No Surprises Act and message to the legislature that no further action on the state level is necessary, either relative to an OON default rate or notice and disclosure/price transparency requirements. The following two bills are refiles, and are opposed by MACEP:

• HB997, An Act to protect health care consumers from surprise billing (Donato) Notice and disclosure/price transparency requirements.
  Would reimbursement emergency and non-emergency OON services at the carrier’s median contracted rate.
• SB645, An Act relative to out-of-network billing (Friedman) Refile - SB674. Died in Senate Ways and Means
  Summary: Directs the Center for Health Information and Analysis to calculate non-contracted commercial rates for emergency and non-emergency services; requires insurers to describe the out-of-network consumer protections in GL 176O; requires the division of insurance to implement the rates calculated by CHIA; requires the rates be revised every 5 years; prohibits balance billing (the practice of providers billing patients for services that have been paid for by the insurer) and declares it an unfair and deceptive business practice; exempts insurers from the requirement to pay when the insured had reasonable opportunity to select in-network providers; allows self-funded ERISA plans the option to be subject to provisions.
  S.645 is the most likely bill to move, or to be used as a vehicle, if any state action is to take place on this issue in this session.

HB 4922 expands to EMS

HB 4459 & 4460 passed in 2020; both prohibit balance billing beyond a patient’s in-network cost-sharing obligations. Rate setting provisions benchmark payments at the greater of 150% of Medicare or the median in-network rate negotiated by the carrier. The arbitration provision in H 4459 is narrow and requires physicians to meet several burdensome requirements to prove the occurrence of a “complicating factor” in order to receive increases in payment for emergency services.

MNACEP has met with legislators to offer technical advice and support of SF#4012 the Prompt pay for Emergency Room Care and Ambulance services. This bill would mandate health plans with high deductible enrollees pay the providers up front.

AB 469, which modifies the federal NSA. Regulatory rules still in process, NV ACEP lobbying to alter.

NJ arbitration will likely continue as a state-level dispute resolution process.

Senate Bill 46 was filed that would require an estimated cost be provided for emergency care "as soon as reasonably possible."

HB 99 regarding patients' coverage for emergency services continues to have hearings before the House Insurance Committee. Ohio ACEP continues to advocate for this Prudent Layperson Bill that would prohibit insurers from denying coverage for an ED visit without doing a medical review of the claim first.

Successfully defeated HB 2042 in 2021, leaving federal NSA operant.

Tennessee did not engage in out of network payment issues.  

As of January 1, 2020, SB1264 banned out of network balance billing for plans regulated by the Texas Department of Insurance and the teachers retirement system. Established an IDR process.

Washington state established a balancing billing prohibition and payment law in 2020.