Many healthcare consumers have experienced going to the hospital to receive care after checking that the hospital selected was in the carrier’s network, only to later discover that one of the doctors who provided care was considered out of network. Often these providers are deemed “hidden providers” such as radiologists, anesthesiologists, and pathologists who perform medical services behind the scenes. For many years, most insurance carriers would pay all bills charged by these providers regardless of their network status. However, as the service costs continue to increase, insurance carriers have modified their practice, and now are reimbursing these providers what they would pay other similar in-network doctors for the same services. That has led to many patients receiving a balance bill from the out of network doctor for the difference between what they charge and what the insurance carrier is willing to pay.
To protect consumers against balance billing, many states are enacting laws that limit patients’ liability for these additional costs when they go to an in-network hospital and then unknowingly receive care from an out of network provider. Beginning July 1st, California is the latest state to enact consumer protection against balance billing. Under the new California law, “if you visit an in-network facility — such as a hospital, lab or imaging center — you will be responsible only for your in-network share of the cost, even if you’re seen by an out-of-network provider.” California is now one of 21 states with some form of consumer protection against balance billing. Unfortunately, many of these 21 states have protections for consumers only in limited situations such as emergency care or on certain types of health plans.
North Carolina is one such state that provides protection against balance billing, but only for emergency care received in the emergency department when performed by out of network providers. This trend is something to monitor, and moving forward North Carolina consumers (as well as many other states) are optimistic that enhanced protections are passed by local legislators. Until such protections are passed, patients will need to remain diligent and ask prior to receiving services if all medical professionals providing the care are in network with their insurance plan.
If you would like more information on balance billing or suggestions for consumers in trying to assure that only in network providers perform medical care please reach out to HCW.