Update to the Surprise Billing Legislation from Late 2020

In late 2020, we reported the good news that the State of Ohio has passed legislation to curtail “surprise billing.” This was great news given that many of the major carriers in the state were paying claims out-of-network for peripheral services related to emergencies, anesthesia, radiology, and pathology services, which are not subject to patient choice in most instances.

The appeals process for these non-network claims to be paid at the in-network benefit level also became more stringent causing a lot of member, client, and broker dissatisfaction, expense, and time to resolve. The new state-based legislation opened pathways to require both insurance companies and providers to come to an agreement on reasonable payments to remove this burden on patients going forward.

The state legislation, however, did not impact air ambulances because they are regulated by the Federal Aviation Administration. While playing a critical role in life and death situations, air ambulances have extremely high costs, which in turn have become a huge patient burden since nearly all are run by out-of-network providers. After the insurance companies paid these claims out-of-network and up to the “reasonable and customary” amount, a Health Affairs study published in April 2020 found that patients received balance bills with a median cost of $21,698!

While there is a lot of frustration and debate about the most recent coronavirus relief package signed by Congress, the $900-billion deal included a nugget that will genuinely help patients in this situation, though not until 2022. The provision forbids surprise bills from hospitals, doctors, and air ambulances. Starting in 2022, providers and insurers will have to settle bills through arbitration under Federal law as well.

The next year will still present challenges for patients who need air transportation. In the meantime, our recourse as brokers is to help members in these situations as much as possible. We must place pressure on insurers to negotiate arrangements that don’t penalize members and on elected officials when and if those negotiations fall through.

Check out this article from Kaiser Health News for additional information about updates to cost transparency.