Press of Atlantic City

Out-Of-Network 'Surprise' Medical Expenses Bill Continues In 2017

Press of Atlantic City — December 27, 2016


Advocates will continue to push for legislation next year to protect consumers from getting bills for "surprise" out-of-network medical expenses.

State lawmakers, consumer advocates, health insurers and health providers have been on an eight-year mission to enact legislation that would regulate and control out-of-network medical bills New Jersey patients may get unexpectedly.

A Senate bill, sponsored by Sen. Joseph Vitale, was put on hold last week when the Senate Budget Committee delayed its hearing because several stakeholders asked for more time to review amendments made just days earlier. A companion bill has been working its way through the Assembly.

Vitale, D-Middlesex, said the priority of the bill is consumers, and they will be the ones who largely benefit from the legislation. It has taken years for involved parties to compromise on how to reduce balance billing, or extra medical billing, because the issue is so complex, he said.

Passing out-of-network legislation would mean New Jersey would join several other states, including New York and California, which have similar laws in place to protect consumers from getting billed for things such as an unexpected medication or a consultation from an out-of-network specialist during surgery.

Out-of-network charges from doctors, hospitals, health care providers and gaps in insurance coverage have become an increasing concern for patients. Supporters of the bill stated about 168,000 consumers in the state are charged large sums of money for unexpected medical bills every year.

Out-of-network issues have resulted in an additional $1 billion charged to New Jersey's 5 million privately insured consumers in the form of higher premiums, according to research from New Jersey Policy Perspective.

Maura Collinsgru, leader of New Jersey Citizen Action's NJ For Health Care coalition, advocated for consumers as the bill was discussed. She said the coalition's primary objective is to fix a flaw in the health care system that hurts consumers.

"Consumers do everything they should and can to make sure they are at an in-network facility, but yet they are still victimized by surprise bills," she said. "This has to stop. And the indirect cost is something we all bear."

Representatives from hospitals, other health care providers, health insurance companies and consumer protection groups all agree the out-of-network billing practice is an issue, but coming to a solution that benefits all stakeholders is easier said than done.

"You might write in a certain provision, but because it's so complex, it can have unintended consequences or impacts," said Kerry McKean Kelly, vice president of communications at the New Jersey Hospital Association.

The association represents hospitals, health providers and professionals who want to ensure that they are still paid fairly for their work if out-of-network costs become the responsibility of the heath provider or insurance company.

A solution in both the Senate and Assembly versions of the bill is to pay hospitals and health care providers for this type of billing using reimbursement rates that Medicare uses. Health providers were initially concerned because Medicare rates are often below the cost of care, Kelly said.

Stakeholders recently sat down with Vitale and other legislators to come to an agreement on some of those issues, but discussion will have to continue into next year.

Health insurers have a stake in the legislation, too. Vitale said insurers want to make sure they will not be overpaying for out-of-network services.

"Through their efforts, the sponsors are closer than ever to passing out-of-network reform legislation, and we are optimistic that they will achieve that goal to put an end to surprise medical billing and price-gouging," Horizon Blue Cross Blue Shield New Jersey said in a statement.

Collinsgru said much of the debate has been "on the question about leverage between providers and insurers, but what gets lost is that consumers have no leverage."

"Consumers are the victims every time this happens. It needs to stop," she said.

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