Thank you for taking action!

SB 259 "Out-of-Network Health Care Provider Charges" was defeated thanks to you and organized medicine!

Our analysis of this bill was that:

  • The issues surrounding OON provider charges are more complex than those addressed in this legislation. Not all providers choose to be out of network. Plans are narrowing their networks and are deselecting physicians without cause and disrupting continuity of care between physicians and patients.
  • The bill provides unfair bargaining power to health plans during contract negotiations with physicians, even with larger multi and single-specialty practices. These negotiations are often conducted between Fortune 100 insurance companies with huge infrastructure and small physician practices. One of the last remaining bargaining points physicians have is not contracting in order to compel plans to set fair and reasonable business terms for in-network services. Allowing plans to pay their average in network rate for the relevant geographic area places a cap on OON charges, and de facto sets the contract (par) rates. This, in effect, is a rate regulation by health plans.
  • The required filing of a lawsuit to collect reasonable OON charges will increase administrative burdens and practice costs on already stressed physician practices.  This absolutely adds to physician administrative costs and is literally not financially sustainable for physicians. 
  • Before services are rendered physicians will be required to notify insured persons of "out of network" status if reasonably practicable. The provider's OON status will often not be known given multiple products being sold by individual health plans and the movement to commercial narrow network plans also being sold. Such notification places the consumer in the untenable position of making a last minute choice or being liable for OON charges.
  • Capping out-of-network payments to "at least carrier's average in network rate for the relevant geographic area" will incentivize plans to set their in network rates very low (see Report of Office of the Attorney General, State of NY, The Consumer Reimbursement System is Code Blue - legal precedence that carrier's do not set reimbursement at a fair and reasonable amount.)
  • Health plans are required under current law to hold the patient harmless from OON billings. Health plans have failed to put adequate processes in place to assure that these consumer protections are implemented. As a result, consumers are complaining that they feel obligated to pay the OON provider themselves.
  • Charitable hardship exemptions will go by the wayside. Threatening physicians with additional liability exposure will shut down charitable hardship exemptions. The bill does not state how carriers will determine if the insured did not qualify for a charitable exemption or what proof would be necessary.  The plans will have the unfettered ability to declare that a particular service is a per se deceptive business practice and the physician would have to sue in civil court to get paid for services.

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