Families USA Health Action WorkshopProvider Access: Network Adequacy and Balance Billing

January 22, 2015Amanda Peden, MPHHealth Policy Associate, Community Service Society of NY and Health Care For All New York Coalition

What’s the issue?

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“Surprise” medical bills #1 complaint for state insurance regulators/AG office

Lead to medical debt‒ #1 complaint for

Consumer Financial Protections Bureau

‒ 43 million Americans unpaid medical debt on credit cards

‒ Leading cause of personal bankruptcy

The problem Big, unexpected bills

– Surprise bills even though consumer does everything right– Excessive bills for Emergency room

Inadequate & outdated provider networks Inadequate disclosure and price transparency OON coverage can be illusory (low reimbursement)

It was all legal!‒ Consumers had no bargaining power or rights (except for HMO)

‒ No authority for well-intentioned regulators to act

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Fixing the problem: a brief timeline

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Late 90s

April 2015

HMOs have protections, but nobody else…

DFS releases report: An Unwelcome Surprise

2012

2008

HCFANY begins

advocating for surprise bills protections

2013

2014Surprise bills

legislation fails in Assembly

Surprise bills legislation PASSES!

New law takes effect

How does the law address the problem?

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1. Holds consumers harmless‒ Pay in-network cost sharing for surprise bills at participating hospitals,

ambulatory surgery sites, and when referred for OON services‒ ER care (carriers pay, consumers only have to pay in-network cost sharing)

2. Establishes an independent review process for OON bills‒ Bills resolved between carrier v. provider or uninsured v. provider‒ “Baseball” arbitration (forces reasonableness)

3. Improves disclosure by insurance plans and providers‒ Hospitals: standard charges, which insurance it takes and if MDs are “par”‒ Providers: carriers, how much consumer might pay (upon request)‒ Carriers: reimbursement methodology and how it compares to UCR

4. Extended network adequacy protections to more types of insurance plans; provides care through OON provider when no in-network provider; expands external appeal rights to these situations

5 strategies for winning OON protections

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1.Show the problem

2.Educate the legislature

3.Leverage your allies

4.Engage the media

5.Make sure you get the right solution

(1) Show the problem

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Identify and quantify the problem ‒ DFS report issued in 2012‒ Community Health Advocates

(consumer assistance) OON billing cases

Have compelling client stories− Get a “super” or activist consumer to

lobby with you− Prepare them to be in the media

Consumer!

Consumer!

(2) Educate the legislature

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Ask the Legislature to hold a hearing − Or hold one yourself!

(3) Leverage your allies

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Leverage your usual allies− Work with Coalition partners

− Work with other coalitions

− Work with like-minded consumer groups

Collaborate with “non traditional” allies− Health plans

− Provider trade groups

(4) Engage the media

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Hold press conferences− With key partners, consumers,

and state regulators if you are working together

Media buys− Consider placing ads on political

blogs or low-cost papers in low-rent districts

(5) Make sure you get the right solution

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Discuss with colleagues

Do research on other state laws

Stick around for implementation − Make sure regulations and guidance reflect consumer concerns

− Consumer education and outreach

− NY Law provides for “out-of-network reimbursement rate workgroup” to look at OON coverage, reimbursement rates