Health insurance agents and brokers have been trying to get someone out there to do something about the balance billing problem for years.
The most upsetting version of the problem occurs when a consumer with a network-based health insurance plan goes to an in-network hospital or an in-network clinic — or makes other reasonable efforts to seek in-network care — and then discovers, when the bill comes, that one or more of the providers was out-of-network after all.
In many states, the out-of-network provider has no obligation to hold the billed amount to a "reasonable and customary charge," a "usual and customary charge," a charge based on a predetermined multiple of the Medicare rate, or any other amount related to what patients typically pay. The provider may start out demanding an amount far higher than the average amount patients typically pay for that kind of care.
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The provider will often knock the amount demanded down if patients call to complain, but, in some cases, the provider will stick to the original billed fee, or discount that original fee down to a "discounted" amount that is still much higher than the typical amount.
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JoAnn Volk of the Georgetown University Center on Health Insurance Reforms gave a presentation on how states are handling the issue Sunday, at an in-person Health Insurance and Managed Care Committee session in Chicago, at the summer meeting of the National Association and Insurance Commissioners (NAIC).
The committee has completed work on the major regulatory projects needed to bring most Patient Protection and Affordable Care Act of 2010 (PPACA) requirements and programs to life. Balance billing may rise to the top of state regulators' major medical insurance to-do lists, as they wait for the detailed reports they need to respond to how PPACA has affected health insurers' finances.
For more about what Volk said, based on a written version of her presentation included in the Health Insurance and Managed Care Committee's packet, read on.
1. About a quarter of the states have set some kind of statutory limits on balance billing.
Consumers who do not understand their plans, or ignore plan network rules, could end up receiving bills for out-of-network, and being responsible for the balance not paid by the insurer, for routine care received on an outpatient basis.
