Medical bill Twenty-one states have already put in place patient protections via law or regulations, with just six having what think-tank the Commonwealth Fund terms comprehensive protections. (Photo: Shutterstock)

Rhode Island may be taking on the nasty surprise of balance billing on behalf of residents, with legislation under consideration in the Senate that would limit what a patient has to pay out of pocket for an emergency department visit or other needed treatment. The provider would have to bill the insurer using a reimbursement rate calculated by the state’s insurance commissioner.

According to a Modern Healthcare report, the bill also provides for arbitration to resolve disputes between providers and insurers.

While the state’s insurance commissioner would assist in determining reimbursement rates to be paid by insurers for out-of-network care providers, the provider could bill the insurer directly and the two could work out a higher reimbursement rate between them—but the patient wouldn’t be liable for any balance.

Related: 5 reasons to consider adopting reference-based pricing

But there are conditions: says the report, “Only patients who can’t get the treatment they need from one of the providers in their network could qualify for the bill’s safeguards, and they wouldn’t apply to health care services if providers have set fee schedules.”

Twenty-one states have already put in place patient protections via law or regulations, with just six having what think-tank the Commonwealth Fund terms comprehensive protections. The Fund also says that insurance commissioners in those six states have had some success in cutting down on balance billing. Those states’ protections apply to both emergency departments and in-network hospitals, apply the laws to both HMOs and PPOs, provide a hold-harmless clause for patients and also a dispute resolution process for providers and insurers to resolve their differences.

Rhode Island’s legislation comes as many in the industry are closely watching a balance-billing lawsuit in Virginia, the first reference-based pricing-related suit in the country. The case, in which a hospital is pursuing a patient for the balance of a hospital bill, has already lasted for close to four years and been heard in two separate courts.

 

The Modern Healthcare report points out that provider groups haven’t taken strenuous action on the topic of balance billing, but adds that “A brief from the American Medical Association says policymakers should address the root causes of unexpected costs by making sure carriers have adequate provider networks and that carriers offer the coverage promised to their enrollee if the person has to go out of network.”