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Avoiding High Medical Bills: ODI Moves Forward with Provider Network Disclosure Amid Calls to Do More

The Ohio Department of Insurance (ODI) took the next step toward finalizing a rule that will help Ohio consumers get better and more timely information about provider networks. Without access to their insurers’ provider networks, consumers can get hit with high costs for using out-of-network providers.

On July 19, 2015 ODI held a public hearing on proposed Rule 3901-8-16, which will require insurance companies to regularly update their network lists, make them more available to enrollees and prospective enrollees, and provide information about the cost of out-of-network services.

Ohio Consumers for Health Coverage provided written and oral testimony in support of the rule, but with some strong caveats about the rule’s limitations and need to go further. Also testifying was Janet Shaw, Executive Director of the Ohio Psychiatric Physicians Association (OPPA), who supported the rule but urged that more data be collected and made available pertaining to the number of in-network and out-of-network claims that insurers handle. Wendy McVicker of Athens shared her story of being stuck with $11,000 in bills from an emergency life flight to a Columbus hospital from Athens following a serious bike accident. The air ambulance company was not in her network, and her insurance and a provider discount covered about $14,000 of the $25,000 bill. She urged ODI to strengthen the rule to address the issue of “balance billing” – which occurs when the insured person is expected to pay the balance due after the insurance company only pays a portion of the bill for an out-of-network provider. As Wendy noted, she had no choice in the life and-death situation but to go with the air ambulance offered. Tim Maloney, Vice President of Payer Contracting for the University of Cincinnati Medical Center, also offered support for the rule and especially noted that it is important that their staff can access updated patient directories so that they can link UC patients to providers in the patient’s network.

Here is what OCHC would like to see ODI do:

  • Hold consumers harmless from balance billing when the consumer did not select the out of network provider;
  • Require insurance companies to offer an adequate selection of providers;
  • Require an in-network hospital or other facility to assign to a patient only providers who are in the patient’s network when available, and take steps to assure that there are available at the facility providers of all specialties affiliated with each health plan in the service area.

OCHC also commended the Department for proposing that insurance companies must provide consumers with co-pay, co-insurance, and deductible information pertaining to an out-of-network provider when requested, but argued that the information provided should be binding on the insurance company. Under the rule, the information provided is not binding.

OCHC also urged ODI to require the provider directory to list all staff of its in-network facilities who are NOT in the health plan’s network. The rule in its current form simply requires “a general statement notifying enrollees that there may be providers of services at the facility, such as anesthesiologists, radiologists, and laboratories that are not in-network, and a method for contacting the issuer [insurance company] to obtain more detailed information.”

Kathleen Gmeiner, who provided the OCHC comments, stated: “Simply saying that ‘there may be providers who are not in-network’ provides the consumer no information to make an informed decision. It is also pointless to simply tell the consumer how to contact the issuer for more information, because in the plan selection process it is not realistic and often not possible to obtain the information of what providers are not in the network. OCHC strenuously urges that the rule be revised to require the issuer to provide a listing of all providers affiliated with the facility; and a listing of any providers providing services at the facility who are not in-network.”

Under the proposed rule, the insurance company’s obligation to update the directory is triggered if the physician or hospital tells the insurance company of a change that impacts their participation in the network, OR, if in the course of business, such as claims processing, it becomes apparent to the insurance company that there is a change in status. OCHC and OPPA both urged that the insurance companies should be required to take stronger action to confirm that a provider is still in the network. OCHC urged that the insurance companies be required to routinely communicate with network members to confirm that they remain in the network. OPPA proposed that the insurance companies be required to review the claims history of each psychiatrist listed and remove from the directory any psychiatrist who is not actively submitting claims.

Finally, OCHC supported requirements in the rule to make sure that provider directories take into account the needs of persons with disabilities and limited English proficiency. OCHC also supports a requirement that a health plan give a consumer notice when his/her provider drops out of the network.

Next step: ODI finalizes the rule, taking into consideration the comments made, and takes the rule to the legislature’s Joint Committee on Administrative Rules (JCAR). The Ohio Department of Insurance expects the rule to be generally effective 1/1/16, but a few provisions will not go into effect until the following year.