I have an article up at healthinsurance.org that assesses (in more detail than the previous post here) the consumer protections against balance billing in the model law recently adopted by the National Association of Insurance Commissioners.
A key question is what happens after a patient forwards a balance bill to her insurer for negotiation or mediation. Can it come back to bite her? There's some precedent in Texas law. Here's the gist:
If adopted as is, how fully will the model act protect a balanced-billed patient who exercises her option to send the bill to her insurer? "If it goes to mediation, the intention is that the patient will be held harmless," say Stephanie Mohl of the American Heart Association, who served as a consumer liaison to the NAIC and advocated for balance billing protections.I hope you'll click through and read the whole.
The model act does not explicitly guarantee, however, that once the insurer settles the bill with the provider, it won't hold the patient responsible for a portion larger than he would pay for in-network care. The Texas law, upon which this provision is most closely modeled, does not provide such a guarantee, according to Stacey Pogue of the Texas-based Center for Public Policy Priorities.
In practice, however, Pogue says that when patients do initiate mediation, the system seems to be "working really well." Anecdotally, she has heard (mainly from insurers) that the bill is usually resolved with a brief phone call, and insurers usually cover the whole.
Pogue adds two caveats, however. First, the mediation option is generally buried in a balance bill's fine print, and many patients may not notice it or exercise the option. Second, if the patient's in-network obligation is a coinsurance payment -- a percentage of the provider's fee rather than a fixed amount per procedure -- she may be on the hook after mediation for a percentage of a higher bill.
The NAIC model act, like the Texas law, is likely to limit but not entirely end patients' exposure to balance billing for care at an in-network facility. It may also reduce the incidence of balance billing by making insurers and providers work together to resolve disputes. Pogue says that insurers tell her that "mediation in Texas is opening the door for more contracting" -- that is, helping to make narrow networks less narrow. "It's an administrative hassle to mediate claims -- easier to negotiate and come up with a contract," Pogue observes.