Consumer protection officials have downgraded the issue of surprise balance bills from one of the biggest consumer challenges to "barely an issue" since the Emergency Services and Balance Billing Law went into effect in 2014.
Consumer complaints about surprise medical bills in New York have dropped sharply since the state enacted a law in 2014 protecting consumers against certain charges for out-of-network (OON) services not paid by an insurance plan, finds a new case study by researchers at Georgetown University's Center on Health Insurance Reforms.
The analysis also examines the effects of the law on providers and payers, since a key component of the law is a "baseball-style" arbitration process to resolve disputes using an independent dispute resolution (IDR) process.
Under the law, when there is a dispute, the payer and the physician must submit their best offer to the arbiter, and the arbiter chooses either the provider bill or the insurer's payment as reimbursement for services.
The case study is based on a review of New York's law, published analyses, and ten structured interviews with state regulators, consumer advocates, insurance company representatives, physician and hospital representatives, and expert observers.
It shows four ways the law has improved the surprise billing issue for consumers:
- In the five years since the law went into effect, consumer protection officials have downgraded the issue of surprise balance bills from one of the biggest consumer challenges to "barely an issue."
- An analysis of surprise balance billing-related calls to the Community Service Society's consumer help line found that 57% were resolved because to the law's protections.
- Another analysis of claims data found a 34% drop in out-of-network billing in New York since the law was in effect.
- Several stakeholders reported that the accuracy of insurers' provider directories had improved since the law was enacted, although problems remain.
One the payer and provider side, the researchers found that:
- Survey respondents largely viewed the IDR process as fair.
- As of October 2018, IDR decisions have been roughly evenly split between providers and payers, with 618 disputes decided in favor of the health plan and 561 decided in favor of the provider.
- Insurers have tended to win most out-of-network emergency services disputes (534-289), while providers have won most surprise bill disputes (272-84).
- Insurers and physicians have tried to work out their payment disputes before filing with IDR.
- One analysis cited in the Georgetown case study found a 13% average reduction in physician payments since the law was enacted.
Although the researchers say that New York's Emergency Services and Balance Billing Law has been successful in protecting patients from some surprise bills, three main challenges remain. They are:
- Inadequate provider directories
- Physicians' office staff misinforming consumers about their network status
- A lack of protections for people enrolled in self-funded employer plans, for which federal legislation is needed
Alexandra Wilson Pecci is an editor for HealthLeaders.
Consumer complaints about surprise billing in New York State have dropped since 2014.
Payers and providers largely view the arbitration process as fair.
Payers and providers are trying to resolve disputes on their own before resorting to arbitration.
Federal legislation is needed to protect all patients.