Out-of-Network Payments

In 2017, "Surprise Billing" legislation was ultimately approved by the Legislature and signed by the Governor ended up having only a nominal effect on our Emergency Department Physicians as it covered only those cases where the billing in question was for over $1,000. 

C.R.S. 10-16-704 passed in 2019 capped OON reimbursement at the greater of 110% of the carrier's median in-network rate or the 60th percentile of the APCD.

Ban on balance billing with state IDR process for disputes. If a physician is OON, the insurer is supposed to pay the physician’s usual and customary provider’s charges (which should induce negotiated contracts to be in-network).

The current state IDR process is broken; insurers are "opting out" of participation. This leaves only the courts as a remedy for bad payer behavior. 2024 legislative efforts to make insurer participation compulsory if an IDR claim is pursued. This has stalled and will likely not pass in 2024 but legislative sponsors indicate they will bring this back in 2025.

Other Resources

Committee Substitute for Committee Substitute for Committee Substitute for House Bill No. 221 (2016 law on Out of Network and process to appeal)

State regulated Surprise Medical Billing legislation (HB888) passed and in effect 1/1/2021. Network Adequacy legislation (SB20) passed and in effect 1/1/2024.

Out-of-network payment – MACEP joins the Mass Medical Society and the Mass Hospital Association in support for the federal No Surprises Act and message to the legislature that no further action on the state level is necessary, either relative to an OON default rate or notice and disclosure/price transparency requirements. The following two bills are refiles, and are opposed by MACEP:

• HB997, An Act to protect health care consumers from surprise billing (Donato) Notice and disclosure/price transparency requirements.
  Would reimbursement emergency and non-emergency OON services at the carrier’s median contracted rate.
• SB645, An Act relative to out-of-network billing (Friedman) Refile - SB674. Died in Senate Ways and Means
  Summary: Directs the Center for Health Information and Analysis to calculate non-contracted commercial rates for emergency and non-emergency services; requires insurers to describe the out-of-network consumer protections in GL 176O; requires the division of insurance to implement the rates calculated by CHIA; requires the rates be revised every 5 years; prohibits balance billing (the practice of providers billing patients for services that have been paid for by the insurer) and declares it an unfair and deceptive business practice; exempts insurers from the requirement to pay when the insured had reasonable opportunity to select in-network providers; allows self-funded ERISA plans the option to be subject to provisions.
  S.645 is the most likely bill to move, or to be used as a vehicle, if any state action is to take place on this issue in this session.

HB 4922 expands to EMS

HB 4459 & 4460 passed in 2020; both prohibit balance billing beyond a patient’s in-network cost-sharing obligations. Rate setting provisions benchmark payments at the greater of 150% of Medicare or the median in-network rate negotiated by the carrier. The arbitration provision in H 4459 is narrow and requires physicians to meet several burdensome requirements to prove the occurrence of a “complicating factor” in order to receive increases in payment for emergency services.

MNACEP has met with legislators to offer technical advice and support of SF#4012 the Prompt pay for Emergency Room Care and Ambulance services. This bill would mandate health plans with high deductible enrollees pay the providers up front.

AB 469, which modifies the federal NSA. Regulatory rules still in process, NV ACEP lobbying to alter.

Since 2018, New Jersey has a state arbitration process for state regulated plans and ERISA plans that elect to opt into the state arbitration. Arbitration is a baseball arbitration model.

Senate Bill 46 was filed that would require an estimated cost be provided for emergency care "as soon as reasonably possible."

Numerous bills related to health insurance were introduced in the spring. All bills aim to alleviate the burdens that insurers impose on healthcare providers and patients. Ohio ACEP will be working with other healthcare organizations to support this effort.

SB 165 – Prohibits insurers from denying claims based solely on “diagnosis code or impression, current ICD code, duration of an appointment as deemed clinically necessary by the enrollee's provider or select procedure code relating to the enrollee's condition.” Clarifies that the prudent layperson standard includes mental health conditions.  Specifies that health plans shall not require patients to self-diagnose. Specifies that insurers “shall not reduce or deny a claim for reimbursement based on the absence of an emergency medical condition if a prudent layperson with an average knowledge of health and medicine would have reasonably expected the presence of an emergency medical condition.” SB 165 is a revamped version of HB 99 from the previous General Assembly. Status: Referred to the Senate Financial Institutions, Insurance and Technology Committee.

SB 162 – Limits the time insurers have to recoup payments to the amount of time providers are given to submit claims. It also prohibits insurers from charging a fee to appeal recoupments. Status: Referred to the Senate Financial Institutions, Insurance and Technology Committee.

SB 164 – Prohibits insurers from using AI as the sole basis for making claims decisions. Requires insurers to submit a report to the Ohio Department of Insurance outlining their use of AI. Status: Referred to the Senate Financial Institutions, Insurance and Technology Committee.

SB 166 – Specifies that insurers are not permitted to charge a provider for receiving reimbursement electronically. Status: Referred to the Senate Medicaid Committee. (A provision on this topic was included in the State’s operating budget)

HB 214 – Creates a prior authorization gold card. Requires insurers to report data on prior authorization. Status: Sponsor hearing held before the House Insurance Committee on May 20, 2025.

HB 219 – Establishes network adequacy standards. This includes ensuring enrollees have access to emergency services at all times. The Department of Insurance would be charged with establishing the ratios for demonstrating adequacy. Status: Sponsor hearing held before the House Insurance Committee on May 6, 2025.

HB 220 – Prohibits plans from denying coverage of a change in medication dosage on a medication that had been prior authorized. Prohibits insurers from retroactively denying coverage of mental and substance use disorder treatment. Prohibits insurers from charging a fee for appealing prior authorization denials. Status: Sponsor hearing held before the House Insurance Committee on May 27, 2025.

House Bill 390 – Puts the responsibility of collecting patient co-pays, deductibles, and other cost sharing amounts on the insurers. Currently, insurers generally require the provider to collect these cost sharing amounts and co-pays, even though they are set by the insurer. Under the legislation, this would take effect January 2027. It also requires all reimbursement for covered services to be made directly to the health care provider. Status: Introduced

Successfully defeated HB 2042 in 2021, leaving federal NSA operant.

Tennessee did not engage in out of network payment issues.  

As of January 1, 2020, SB1264 banned out of network balance billing for plans regulated by the Texas Department of Insurance and the teachers retirement system. Established an IDR process.

Washington state established a balancing billing prohibition and payment law in 2020.

House Bill 313