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New State and Federal Laws Working to Address Out-of-Network Billing in Massachusetts.

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The MA Health Policy Commission writes of new state and federal laws that are working to address out-of-network billing in Massachusetts.

State legislation: Bill S.2984 – An Act promoting a resilient health care system that puts patients first

The Out-of-Network Billing in Massachusetts legislation (S2984) addresses the objectives of a comprehensive out-of-network billing solution:

  1. Reduce OON billing scenarios: New disclosure and transparency requirements for health care providers and insurers in advance of non-emergency procedures
  2. Remove patients from the payment equation: Prohibits OON providers who fail to provide the required notifications from balance billing (subject to fines beginning 2022)
  3. Establish reasonable and fair provider reimbursement: Requires the secretary of Health and Human Services, in consultation with the Health Policy Commission, Center for Health Information and Analysis, and the Division of Insurance, to develop a report and made recommendations on establishing noncontracted, OON commercial rates for emergency and non-emergency services no later than Septermber 1, 2021.

Out-of-Network Billing: New Federal Law
The No Surprises Act (HR133) addresses the objectives of a comprehensive out-of-network (OON) billing (or “surprise billing”) solution for OON emergencies and certain OON care received at in-network facilities (beginning in 2022):

  1. Reduce OON billing scenarios: New disclosure and transparency requirements for health care providers and insurers
  2. Remove patients from the payment equation: Prohibits balance billing and holds patients harmless to in-network cost-sharing levels.
  3. Establish reasonable and fair provider reimbursement: Following a 30-day period for negotiation, providers and insurers may utilize an independent dispute resolution (IDR) process; IDR entity chooses one of the parties’ final offers (i.e. binding “baseball style” arbitration)
  • Applies to providers, facilities and air ambulances (establishes advisory committee for ground ambulances, which are excluded), and to funny-insured and self-insured health plans

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