January 7, 2016
Winning Strategies to Protect Consumers from Surprise Medical Bills
By: Diverse Elders

This post originally appeared on the Community Catalyst blog.

by Amber Ma

Even consumers who do their best to get care from providers in their networks may still be charged unexpectedly for out-of-network care – an issue otherwise known as surprise medical bills or balance billing.

Currently, no federal standards on surprise medical bills exist, but the recently updated NAIC network adequacy model act and CMS’ proposed Notice of Benefit and Payment Parameters (NBPP) for 2017 can bolster both federal and state action to protect consumers. However, because both the model act and the NBPP set a minimum floor even if implemented, state-driven protections are still the most effective way to shield consumers from unexpected out-of-network bills. And three state advocacy groups are making strides in advocating for stronger consumer protections against balance billing.

California Consumers Take a Win and a Hit, but Keep Marching On

Health Access California’s work on balance billing complements their on-going work to strengthen the state’s network adequacy standards. California law already protects most consumers who receive emergency services from balance billing. Health Access California wants to extend these protections to non-emergency services when a patient goes to an in-network hospital but is seen by an out-of-network provider they did not choose or know about. The balance billing legislation stalled due to opposition from the California Medical Association, which opposed how out-of-network doctors would be reimbursed for services under the bill.

Advocates did win on a strong provider directory bill, which sets clear guidelines for updating and ensuring the accuracy of provider directories and tackles one of the root causes of surprise medical bills. Moving forward, advocates are confident they can reach agreement among key stakeholders and get policymakers to take action. In order to be successful, advocates will continue to rely heavily on engaging individuals to share their stories, providing testimony to policymakers, engaging with the media, and strengthening the coalition of patient, labor, and business groups that support this legislation.

Provider and Insurer Drama Won’t Get Advocates Down in New Jersey

Along with working closely with policymakers to take action, New Jersey Citizen Action’s story-banking efforts have also built momentum around legislation to end unfair balance billing in New Jersey. Recently, the proposed bill was stalled due to hesitancy among key Senate committee votes, challenging stakeholder dynamics between insurers and providers (along with hospitals), and pushback on a few areas of the proposed legislation. Things got more complicated when Horizon Blue Cross Blue Shield of New Jersey rolled out a tiered network initiative that left many hospitals out of its top-tier plans, further exacerbating the tension between insurers and hospitals. Ultimately, New Jersey Citizen Action and its partners are preparing to push for strong turnout and engagement from their coalition and consumers to pass the bill during the 2016 legislative session.

Texas Gears Up for More Wins

The Center on Public Policy Priorities (CPPP) in Texas published a report in 2014 that has catalyzed awareness and action for greater balance billing protections for Texans. The advocates originally started with a much stronger bill – but because of pushback from a physician group, they reached a compromise. They were successful in lowering the threshold for consumers to do something about balance billing if the extra charges are $500 or more (originally $1,000). Additionally, advocates received an “interim charge” for the House Insurance Committee to spend time studying the problem and potential solutions. Advocates will actively participate in the process.

Between now and the next legislative session in 2017, advocates will be making sure these changes work for consumers. They have succeeded in getting media coverage on the bill and are generating a buzz about the issue via social media, as well. By engaging consumers about what protections they have and keeping a close watch on the issue, advocates hope to gain a better understanding of how to protect consumers from balance billing during the next legislative session in 2017.

All this to Say…

Time will tell if federal regulations on balance billing get taken up, but we are hopeful that state momentum on the issue will lead to successes in ending unfair billing practices.


The opinions expressed in this article are those of the author and do not necessarily reflect those of the Diverse Elders Coalition.