To help inform policymakers as they debate a range of patient protection options, we have identified key considerations for addressing surprise medical bills. These considerations are informed by policies already adopted in more than half of states. One key consideration is transparency standards.
NOTE: Congress recently enacted the federal No Surprises Act, a new federal law that protects patients from surprise medical bills in all states. These comprehensive new protections will go into effect beginning in 2022 and will protect patients from surprise medical bills for emergency services (including air ambulances) and non-emergency services provided at an in-network facility. Patients’ out-of-pocket costs will be limited to the costs they would have paid if they had received services from an in-network doctor, hospital, or other health care provider. The considerations here may continue to be relevant (especially for state policymakers interested in pursuing separate protections) but we recommend that readers learn more about the No Surprises Act here.
Some surprise bills—primarily for non-emergency services—arise due to inaccurate or incomplete information about whether a provider is in an insurer’s network. Provider networks can change over time, and provider directories are not always updated. Sometimes providers themselves do not know which plan networks they’re in, leading to patient confusion and surprise bills. Additional transparency requirements, without additional patient protections, will not ensure use of network providers nor solve all surprise bills (such as emergency care, when the patient does not have the option to search for and select an in-network provider). However, policymakers can consider additional ways to improve access to accurate information for patients, insurers, and providers.
To help minimize the potential for surprise medical bills, policymakers may consider specific disclosure requirements for plans and providers. For example, policymakers can require health care providers to disclose the insurance networks in which they participate, the cost of their services, and the possibility that ancillary services (such as anesthesia, imaging, or laboratory services) might not be available from in-network providers. Insurers could be required to disclose and keep up-to-date specific information about their provider networks, cost-sharing requirements, and the coverage available if out-of-network providers are used. By disclosing this information in advance, patients may be able to make alternative arrangements and thus avoid an out-of-network bill.
In some limited circumstances, policymakers may want to allow surprise billing protections to be waived by patients and providers. A patient might be willing to waive their surprise bill protections if, for instance, a patient makes an informed choice to obtain services from an out-of-network provider (such as a specialty surgeon). Policymakers might want to distinguish these circumstances from instances where an in-network provider is unavailable, or it would be burdensome to reschedule a procedure. Policymakers would need to clearly define how consent is established and how much notice is required.
Some insurers are already required to maintain updated provider directories to help patients understand which providers are in network or not. However, such requirements do not exist in all states, nor are they always enforced where they do exist. Policymakers should also consider providers’ responsibilities for accurately informing patients about their network status, and holding them accountable if they misinform patients.
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Our goal is to help policymakers adopt comprehensive surprise billing protections for patients. Policymakers and staff can contact our team about a specific question or with a broader request for technical assistance. Our experts are available to review materials and consult on policy solutions.