2016: Year in Preview

Picking up the tab: Out-of-network bills will be a hot issue


Jan Greene

The legislative response to consumers receiving surprise medical bills after a visit to the hospital is likely to boil over in 2016 after simmering in 2015. The problem stems from the inability of health plans and out-of-network hospital specialty providers to agree on a proper fee, so consumers end up being billed the balance. Several states are interested in following the lead of New York, which set up a mediation process that keeps consumers out of the middle of these billing disputes. California came close to passing an out-of-network billing law this year, and there’s interest in Pennsylvania, New Jersey, and elsewhere.

The issue’s national profile is likely to be raised following the introduction of legislation in Congress. Rep. Lloyd Doggett, a Texas Democrat, and 20 co-sponsors in October offered the Ending Surprise Billing Act, which would ban balance billing of patients who go to an in-network facility in an emergency; if they go to the hospital in a non­emergency, consumers could not be balance billed unless they get 24-hour notice that an out-of-network provider will treat them, and what it will cost.

While the bills seek to give consumers relief, they can’t really address what is at the heart of the problem: Insurers and providers unable to agree on a fair price for specialty medical services by physicians who don’t contract with that insurer. As their typically obscure contracting issue comes into the open and is debated in public forums, both sides have committed to campaigns painting the other as greedy and unreasonable.