Network Adequacy, Provider Directories and Surprise Medical Bills Families USA Health Action 2016 February 4, 2016

Networks, Directories, Unexpected Bills

30% of privately insured Americans received a surprise medical bill, where their health plan paid less than expected, in the past two years Among those with surprise bills, nearly one out of four got a bill from a doctor they did not expect to get a bill from. Consumers Union National Survey (May 2015)

53% of patients with surprise medical bills reported that the issue was either not resolved as they liked, or not resolved at all. 75% of this “unhappy” group paid the bill in full (57%) or through an installment plan (18%). Consumers Union National Survey (May 2015)

Who’s In-Network at Your Hospital? Source: “Surprise Medical Bills Take Advantage of Texans,” Center for Public Policy Priorities, 9/2014

87% of consumers did not know which agency or department in their state government is tasked with handling complaints about health insurance Many (72%) are unsure if they have the right to appeal to the state/an independent medical expert if their health plan refuses coverage for medical services they think they need. Consumers Union National Survey (May 2015)

NY State received 2,000 consumer complaints a year about medical billing issues ( ) Insurance companies receive 1,400 more Comprehensive set of actions needed to fix the problem 2012 NY Dept of Financial Services Investigation

Consumers receive surprise bills for many different reasons: Missing protections for inadequate networks Inaccurate provider directories Lack of disclosure of provider status for non- emergency care Excessive bills for emergency room care Reduced, skimpy insurance coverage for OON services Difficulties in submitting claims 2012 NY Dept of Financial Services Investigation

1.Accurate and Up-to-Date Provider Directories 2.Meaningful Disclosure of In-Network or Out-of- Network Status 3.Ban Out-of-Network Surprise Balance Billing 4.A Well-Defined Process for Determining Payment of Surprise Bills, such as Independent Dispute Resolution 5.Tell Consumers What Their Rights Are Potential remedies

6.Strengthen network adequacy standards 7.Better disclosure by health plans about OON reimbursement levels (e.g. Usual and Customary Rate vs. 140% of Medicare) 8.Better protections for workers in self-insured plans exempt from ERISA – half of private sector workforce Potential remedies

Advocates Guide

Chuck Bell, Programs Director Consumers Union (914) Contact Information