Patients who get stuck with bills after accidentally going out-of-network will now be protected under two new laws.
The bills take aim at a practice called “surprise billing,” which happens when an insured patient thinks they are in-network receiving care from a contractor there who is out of network. The new state law will go into effect January 2022 and is for fully insured plans.
In emergency situations, patients will most often get two bills: A balance bill and a surprise bill. Both force the patient to pay for out-of-network costs. A balance bill can come when patients show up at the emergency room and they might have to see a physician who is out-of-network. Patients will get a surprise bill when they go to an in-network provider at a hospital for a procedure, but they receive services from an out-of-network physician.
The new law means the provider or insurance company will pay those out-of-network bills. DBL Law health care attorney David Dirr said calls for medical emergencies skyrocketed in 2020 because of the pandemic, which makes a law like this even more important for patients and health insurance companies.
"Hospitals hate dealing with patients who are upset about this, and insurance companies don't like to deal with it either,” Dirr said. “So this was a compromise … an issue that's been bubbling up for a long time. And I think it's going to be good for patients and ultimately save a lot of headaches for providers and for insurance companies."
The federal law protecting against surprise bills comes after years of failed attempts and big lobbying spending on all sides, The Journal-News reported. The federal law also goes into effect in 2022 and covers fully insured and self-insured patients.
The details still need to be worked out on how the federal and state laws will layer together in Ohio.
The Ohio law notably goes a step further, because it regulates when there’s a surprise bill related to an ambulance ride, while the federal law did not cover that scenario.
Loren Adler, associated director at the USC-Brookings Schaeffer Initiative for Health Policy, who has been tracking surprise billing regulations, said with the inclusion of protection from ambulance surprise bills, he believes the state law is meaningful new protection and crafted in a strong manner.
“The ground ambulance market in many states is currently sort of like the wild west, so Ohio’s new law should do a lot to improve payment for ground ambulances and protect at least fully insured plan enrollees from a common source of surprise bills. Hopefully the federal government will eventually add a protection for ground ambulances as well,” Adler said.
The bill signed into law by Gov. Mike DeWine was sponsored by Rep. Adam Holmes, R-Nashport. It was unanimously approved by the Ohio House of Representatives in May and overwhelmingly passed the Ohio Senate in December.
Ohio now has a law that is supported by health plans, providers, advocacy groups and business organizations, Ohio Association of Health Plans President CEO Kelly O’Reilly said. The state and federal laws are similar, she said, but not the same, so they still have to sort out what the unexpected passage of both means.
“It’s like the most 2020 thing ever, that after a decade of doing this, Congress acts the day after Ohio acts, finally, after all these years,” O’Reilly said.
Ohio Department of Insurance officials say they have dealt with surprise billing complaints for years, which surveys indicate are a common experience for patients. In Ohio, on average 18% of emergency visits result in at least one out-of-network charge, per the Kaiser Family Foundation.
“If you or a loved one is having a heart attack, you don’t typically stop to look if the closest hospital is in your network,” said Carrie Haughawout, deputy director of the Ohio Department of Insurance.
Holmes, the bill sponsor, noted that there had been efforts to tackle surprise billing before his bill passed, and he gave credit to former state Rep. Jim Butler, R-Oakwood, for getting the ball rolling. The process at times felt fragile, he said, but it ended up passing with overwhelming and bipartisan support.
“Everybody saw in the COVID crisis and economic crisis, people just can’t afford these kinds of bills now. They can just crush somebody. So it was a golden moment,” Holmes said.
WCPO’s media partner, The Journal-News, contributed to this report.
