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Four States’ Approaches to Tackling Surprise Medical Billing

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In an Opinion piece in STAT News, Robin Gelburd, President of FAIR Health, writes of how four states are tackling the issue of surprise medical billing, using data from FAIR Health to do so.

  • New York: New York’s approach to surprise medical billing is through independent dispute resolution – if a payer and a provider cannot agree on how much the latter should be reimbursed for a service in a surprise bill scenario, they may seek what is known as “baseball arbitration.”
  • Connecticut: Connecticut’s approach to surprise billing is to mandate a specific rate for reimbursement. For out-of-network emergency services, Connecticut requires payment at the highest of three values: (1) the in-network rate (also called the allowed amount) under the patient’s plan; (2) the FAIR Health 80th percentile charge benchmark; or (3) the Medicare reimbursement rate. Nonemergency surprise bills in Connecticut are handled differently.
  • New Mexico: Similar to Connecticut, New Mexico mandates payment for surprise bills at a set rate, but a different one: the 60th percentile of FAIR Health’s allowed amount benchmark for the particular service in the specific geographic area, provided that no payment is less than 150% of the Medicare reimbursement rate.
  • Texas: Texas adopted an approach similar to New York’s in using independent dispute resolution rather than mandated rates to address surprise bills.

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