Massachusetts Medical Society: MMS Comments to Conference Committee on Out of Network Billing in State Health Care Cost and Access Bill

MMS Comments to Conference Committee on Out of Network Billing in State Health Care Cost and Access Bill

While not perfect, the MMS supports the House Out of Network (OON) provisions and appreciates the floor amendments that helped ensure a transparent and independent database, authorized the Division of Insurance with ensuring the fairest possible calculation of “average rate”, and clarified the process for both same-day and recurring out-of-network appointments.  We look forward to working with Conference Committee members on the attached suggestions to further improve the formula, notification processes, and dispute resolution provisions.

The MMS feels strongly that no patient should receive a balance bill for unavoidable out of network care. To achieve that aim, MMS supports a legislative solution that will: require insurance plans to cover their patients and hold them financially harmless for anything more than regular deductibles and cost sharing; and establish a fair reimbursement standard to compensate out of network physicians for care provided. 

Accordingly, MMS calls for the following two changes to the out of network provisions in House 4639:

  • The average contracted rate should be based upon 2017 rates, and these rates should be transparently accessible to providers via a secure web portal.  Additionally, to address ongoing price increases, we would propose applying a price escalator to the 2017 rates as opposed to an annual determination of average contracted rates.  Specifically, we propose increasing the 2017 rates by applying the growth rate of potential gross state product.  We believe these measures will create a more efficient and fair process, as opposed to an open ended, year-by-year re-determination.
  • MMS supports ensuring that patients have the right to all information necessary to know the network status of their providers, and of any potential out-of-pocket costs. MMS urges balance in these “notice” policies to ensure that patients have access to clear and concise information without time-consuming, unnecessary disclosures. The notice provisions as currently drafted in the House bill would require a lengthy disclosure statement be read each time a patient schedules an appointment. We instead urge that only the most helpful information be required to be disclosed, while additional information is made available by the providers upon request of the patient. This could be accomplished via the following amendment to Section 68 of House 4639:

“(b) At the time of scheduling an admission, procedure or service for an insured patient or prospective patient, a health care provider shall: (i) determine the provider’s own network status relative to insured’s insurance carrier and specific health benefit plan and disclose in real time such network status to the insured; and upon request by a patient or prospective patient, shall (ii) notify the patient or prospective patient of their right to request and obtain from the provider provide,…”

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