Julie Silas from Consumers Union presented on surprise medical bills and provider directory inaccuracy in Georgia.

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Julie Silas
February 2, 2016
Finding Policy Solutions for
Provider Directories and
Surprise Medical Bills

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Who We Are – Consumers Union

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Among those respondents,
more than one out of ten
were charged an out-of-
network rate when they
thought the provider was in-
network.
Received a surprise medical bill where their health plan
paid less than expected (higher than the national avg)
1 in 10
Consumer Reports National Research Center – Survey fielded December 17, 2015 thru January 11, 2016
41%
Survey of 407 privately insured
Georgia residents
Overall, the majority of Georgia privately insured residents
assume doctors in an in-network hospital are in-network
66%

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• What are they?
• In-network facility; out-of-network providers
• ER docs, hospital “ologists”
• After care, get the “surprise”
• What is the surprise?
• Higher cost-sharing
• Balance billing
Surprise Out-of-Network
Medical Bills

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• How do they happen?
• Faulty provider directory
• Emergency situation
• No opportunity or ability to choose
Surprise Out-of-Network
Medical Bills

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“The uncertainty is stressful, because in addition to the
constant billing errors having to be resolved, we must now
also constantly be worried about any staff that comes by the
hospital room because they might be secretly preparing an
immense invoice. What recourse does anyone have in such
situations currently – your options are to suddenly cease
medical care, or be forced to pay exorbitant fees for routine
procedures that should be covered under the insurance plan.”
– Kennesaw, GA
“I met the anesthesiologist while on the
table, being prepped for surgery and, I
must admit, did not think to ask him if he
was in-network. Who would? I had to file
some sort of protest but ended up only
paying in-network charges.”
- Atlanta, GA

8. 8
“The specialist & ward (hospital) doctors were standing
there, neither informed me that the specialist DID NOT
accept my insurance. I later received a bill from the
specialist for $6,000.00 for his 3-4 minutes of work.”
– Acworth, GA
“I argued with both Insurer and hospital that
the very nature of an emergency visit
necessitates an evaluation by an emergency
physician, and that to say that an ER is ‘in-
network’ is to imply that the physicians one
sees as ER docs are also ‘in-network.’ My
appeals were simply denied (twice) and my
argument was not addressed. Eventually I
was forced to pay the out-of-network fees.”
– Cartersville, GA

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11. • Very few state laws
• 2/3 had no requirements for
how insurers update their
directories*
• If addressed, often
outdated solutions based
on paper directories
11
Blah
blah
* NAIC 2014 survey of Insurance Commissioners

12. • ACA –addressed provider directories as
part of network adequacy
• Recent federal changes provide stronger
standards – but limited
12
Blah
blah

13. Provider Directory
• Federal Rules
• All insurers provide direct links to online listing
• Updated monthly
• Machine-readable format
• State level
• AZ and VT – update twice/year
• NY – update changes within 15 days
• CA – weekly updates
13
Blah
blah

14. Provider Directory - GOALS
• Anyone can use directory
• Accuracy – updated, and de-list if no
update
• Robust consumer reporting (dedicated
line to report inaccuracies)
• If rely on inaccurate directory = restitution
• Public needs to understand criteria for
creating the network
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Blah
blah

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18. • ACA emergency room rules = in-network
cost-sharing, no protections against
balance billing
• Proposed Federal Legislation (HR 3770) –
rules tied to hospital Medicare payments
• State-based activity – ban on balance
billing applies to insurers/providers
• NY, CT, and MD = laws in place
• At least 12 other states taking action
18
Blah
blah

19. 19

20. 1 Accurate and up-to-date provider directory
2 Disclosure of network status – whether in-
or out of network
3 Ban on balance billing for out-of-network
surprise bills
4 A well-defined process for determining
payment of surprise bills
5 Consumer rights information
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Blah
blah

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Thank you!
Please email
Julie Silas with
any questions:
jsilas@consumer.org
Reports can be downloaded
from:
www.consumersunion.org