Rhode Island may join states trying to shield insured patients from surprise medical bills if they have to visit a physician or hospital out of their carrier's network—also known as "balance billing."
The Rhode Island Senate's health committee is considering legislation this week that would limit a patient's out-of-pocket costs for an emergency department visit or other needed treatment to a co-pay or deductible. The provider would have to bill the carrier using a reimbursement rate calculated by the state's insurance commissioner.
The bill also includes arbitration measures to resolve disputes between providers and insurers.
Rhode Island is following states like California, Florida and New York that have already passed comprehensive laws on balance billing.
This particular proposal is getting its first hearing this week. Rhode Island's 2018 legislative session ends in mid-July.
The state's insurance commissioner would help set the reimbursement rates that the patient's insurer would need to pay to the out-of-network provider. The provider would be able to bill the insurance company directly and both could also work out higher payments.
Only patients who can't get the treatment they need from one of the providers in their network could qualify for the bill's safeguards, and they wouldn't apply to healthcare services if providers have set fee schedules.
So far policy discussions about balance billing have focused on the state level, and a recent analysis by the Commonwealth Fund said that states are the best-equipped to manage the issue.
Of the 21 states that have established patient protections through law or regulations, six have what the think tank calls comprehensive protections.
The Commonwealth Fund also reports that insurance commissioners in the states with comprehensive measures—which apply to both emergency departments and in-network hospitals and apply the laws to both HMOs and PPOs, and include a hold-harmless clause for patients and a dispute resolution process to arbitrate between providers and insurers—have reported some success in curbing balance billing.
Provider groups have tread carefully on the topic of balance billing. A brief from the American Medical Association says policymakers should address the root causes of unexpected costs by making sure carriers have adequate provider networks and that carriers offer the coverage promised to their enrollee if the person has to go out of network.
America's Health Insurance Plans' statement on the issue touts the benefits of provider networks as the best protection for patients.