‘Balance Billing’ Still an Issue for Consumers Under ACA

Insured individuals can still receive unexpected bills for out-of-network medical services under the Affordable Care Act, despite protections in the law designed to protect consumers against medical bankruptcy, Kaiser Health News reports.

According to KHN, insured individuals under the ACA can still face high medical bills under a practice called "balance billing," in which out-of-network providers charge patients for the difference between what patients' insurers cover and what providers' charge for the service.

Insured patients can face this issue when:

• Insurers or providers give false or incomplete information about which providers are in-network;
• Physicians have multiple offices, some of which are not in-network;
• Hospitals use out-of-network physicians; or
• Patients enroll in health plans with narrow networks that do not include emergency department physicians or other specialists.

Insured Patients Susceptible to Balance Billing

Proponents of the ACA have said the law will help reduce the number of bankruptcies that occur for medical reasons. The law includes caps on consumers' out-of-pocket costs and requires insurers to provide coverage for emergency care. In addition, the ACA prohibits insurers from charging members higher copayments if they use ED services at out-of-network hospitals.

However, the ACA does not count consumers' charges at out-of-network providers toward the annual out-of-pocket cap. In addition, the law does not prohibit out-of-network emergency care providers from engaging in balance billing.

Meanwhile, few states have addressed the issue of balance billing. The states that have addressed the practice have done so in limited circumstances, such as for ED visits or for specific insurance plan types, such as health maintenance organizations.

Timothy Jost, a Washington and Lee University law professor, said, "It's not fair and probably not legal that consumers be left holding the bag when an out-of-network doctor treats them" when they are unaware that is the case.

Some Call for More Consumer Protections

Some consumer advocacy groups have called for regulators to place more limits on balance billing. For example, Consumers Union and the American Cancer Society Action Network have called on regulators to place strict limits on the practice when an insured individual receives care from an in-network medical facility.

Consumers Union in a recent letter to the National Association of Insurance Commissioners wrote, "Without protection from balance billing, the cost of out-of-network care can be overwhelming."

NAIC is in the process of updating a model network adequacy rule, which states could use and adapt to regulate their own insurance networks. However, its current draft does not directly address balance billing, according to KHN (Appleby, Kaiser Health News, 2/18).