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Surprise! Balance Billing Prohibitions Coming in 2022

March 2021 - Cleveland Metropolitan Bar Journal
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Lawmakers in Washington and Columbus closed out 2020 by finally addressing an issue that has long vexed consumers of health care — surprise medical bills. The problem is familiar to most. Heart attack, stroke, or trauma victims are transported to an emergency room that does not participate in their health insurance carrier’s network. Or patients receiving non-emergency treatment at their in-network hospital discover afterwards that, unbeknownst to them, the anesthesia team or lab service was out-of-network. Or patients at a smaller hospital need an expensive air ambulance ride for more complex care elsewhere. Later, when the bills come, patients realize that, unlike in-network treatment, their health insurance carrier’s payments cover only a fraction of the "usual-and-customary" charges of the out-of-network provider, and that provider in turn "balance bills" the patients for the difference.

For years, consumer advocates have sought enactment of laws to shield patients from the effects of balance billing, which can lead to considerable debt and even bankruptcy. Despite policymakers’ widespread agreement on protecting patients, the stumbling block has been determining what to do with the portion of the bill not paid by the patient, when the patient’s health insurer and the provider have no "network" agreement in place for payment of charges. Should the physician or hospital accept an in-network rate anyway, and if so, what rate? Should the insurer pay the provider’s full out-of-network usual-and-customary charge? Should the payment in such situations be tied to some benchmark? New federal and state laws answer these questions and also mandate new consumer protections.

Read the article here.

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