Collector - July 2020 - 22

7in10

patients who faced out-ofnetwork bills that they could not
afford to pay did not know at
the time they received the care
that the medical professional
was out-of-network.
Source: 2016 Kaiser Family Foundation survey

22

Patients are often caught off guard by
these medical bills-hence the term "surprise
billing"-because they expected that all care
provided at an in-network facility would be
in-network care. This is especially true in
the case where an insured patient seeks care
at an in-network facility but is unknowingly
treated by an out-of-network practitioner.
Over the years, stories of insured consumers
receiving large, unanticipated medical bills
has provoked the ire of consumer advocates
and politicians who have moved to restrict
these practices.
At the time of publication, there is
currently no federal law addressing the
practice of balance billing, but there are two
bills under consideration in Congress: H.R.
5800, the Ban Surprise Billing Act, and H.R.
5826, the Consumer Protections Against
Surprise Medical Bills Act.
Both pieces of legislation would ensure
that patients do not pay more than what
they would normally pay in cost-sharing
for in-network providers, but the measures
differ in how they determine what insurers
will pay out-of-network providers. There
are also reports that members of the Senate
are negotiating a proposal on the issue,
but legislation has not yet emerged. Also
noteworthy, on June 24, 2019, President
Donald Trump signed Executive Order
13877, Improving Price and Quality
Transparency in American Healthcare to
Put Patients First, to ensure transparency by
health care facilities in the setting of costs.
Notably, neither the House legislation
nor the president's order appear to have any
direct effect on debt collection practices.
ACA will continue to monitor federal
legislation on this issue.

STATE LAWS: AN OVERVIEW
With no federal law currently occupying
this space, many states have moved
to fill the void. Currently, almost
30 states have enacted some level of
surprise billing protection, with other
states considering similar legislation.
According to the Commonwealth Fund,
as of July 31, 2019, California, Colorado,
Connecticut, Florida, Illinois, Maryland,

New Hampshire, New Jersey, New
Mexico, New York, Oregon, Texas and
Washington had enacted comprehensive
protections, with Arizona, Delaware,
Indiana, Iowa, Maine, Massachusetts,
Minnesota, Mississippi, Missouri,
Nevada, North Carolina, Pennsylvania,
Rhode Island, Vermont and West Virginia
having enacted more limited protections.
Surprise billing laws vary from state to
state, but many of the measures provide
protections that apply to both emergency
care by out-of-network providers and
nonemergency care by out-of-network
providers at in-network facilities.
Some of these laws affirmatively prohibit
providers from sending balance bills to
patients and may also limit a patient's
responsibility to in-network cost-sharing
amounts. Some laws require providers to
seek any additional payments from health
insurers and require the provider and the
health insurer to negotiate in the event of
a payment dispute between the health plan
and the provider.
Several of the laws require the use
of an independent dispute resolution
framework. Other measures may also
require providers to make disclosures
about a provider's out-of-network status
before administering care to the patient.
While most of these laws do not
have any specific requirements for debt
collectors, it's still important to be aware
of these restrictions and to work with
medical provider clients to ensure laws
have been followed on the front-end, so
bills that may be subject to balance billing
restrictions are not inadvertently placed
in collections.
Communication with your clients may
be especially important when a law has
recently been enacted or amended, as it
may take time for medical provider clients
to update policies and procedures to
ensure accounts subject to surprise billing
restrictions are handled appropriately.
What follows is an examination of several
recently enacted or amended surprise
billing laws and their implications for debt
collectors and medical provider clients.

ACAINTERNATIONAL.ORG


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Collector - July 2020

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