Model legislation drafted for out-of-network balance billing

A legislative organization calls on hospitals, insurers and physicians to disclose when patients must pay for care.

By — Posted March 29, 2011

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As several states consider whether, or how, to restrict balance billing by out-of-network physicians, the National Conference of Insurance Legislators on March 6 adopted model legislation on the issue.

Rather than explicitly banning or allowing physicians to bill patients when insurance doesn't cover what a physician is owed, the model legislation calls for greater transparency on the part of hospitals, insurers and doctors to alert patients to the possibility that they could end up paying out of pocket for care.

The model bill builds on laws recently adopted in Louisiana and Texas, according to NCOIL's announcement.

NCOIL worked for two years on the model legislation (link).

"At a time when health costs are rising, the model will require needed information about consumer health benefits and financial responsibilities and promote informed decisions," NCOIL President and North Dakota state Rep. George Keiser, a Republican, said in a statement.

The American Medical Association supports the right of physicians to balance-bill patients where permitted by law.

Nine states restrict balance billing by out-of-network physicians, though in most cases the practice is banned for emergency care only.

This year, legislators in several states, including Illinois, Indiana, New Jersey and New Mexico, are considering whether to ban or limit balance billing.

Bills pending in New Jersey emphasize disclosure of potential costs to patients, particularly where nonparticipating physicians work at in-network hospitals.

An Indiana bill introduced Jan. 12 resembles the NCOIL model legislation in requiring conspicuous notice to patients where out-of-network care may require out-of-pocket payment, but also explicitly allows physicians to balance-bill.

Lawmakers in Hawaii are considering a bill that would require insurers to pay both in-network and out-of-network physicians promptly and directly for covered care at either the contracted or usual, customary and reasonable amount.

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