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STATE | ASPS Influences National Model Out of Network Legislation

The National Conference of Insurance Legislators (NCOIL) held its annual meeting last week, during which the Health, Long-Term Care & Retirement Issues Committee deliberated on a proposed model bill, the Out-of-Network Balance Billing Transparency Model Act. NCOIL is a bipartisan group of state legislators who develop recommendations for state policy across the nation. The Conference's goal is to create a model out of network bill that can be replicated in all states houses faced with "surprise billing."

ASPS engaged NCOIL from the onset, submitting recommendations to the Conference in a joint letter cosigned by the American Academy of Orthopaedic Surgeons, American Association of Oral & Maxillofacial Surgeons, American College of Emergency Physicians, American College of Radiology, American Society of Anesthesiologists and the College of American Pathologists. Collectively, the group requested amendments to ensure that patients can purchase and use health insurance products that provide the full continuum of health care needed.

ASPS continued its engagement with NCOIL during the Conference's annual meeting, where a revised draft was considered. ASPS made four recommendations regarding the revised proposal, including a request to ensure that state determinations of health plan network adequacy are comprehensive and rigorous. The Society is concerned as the model bill does not require regulators to assess whether health plans have contracted with in-network physicians at in-network hospitals and facilities. ASPS also commented on a requirement for all physicians to provide a cost estimate of services prior to surgery. As noted in the Society's comments, there are scenarios where last-minute physician substitutions occur. In these cases, cumbersome obligations for providers would further hinder physicians from delivering the highest quality of care. The Society encouraged NCOIL to take these occurrences into consideration and allow for exceptions in these situations.

ASPS supported the use of the usual and customary rate (UCR) for determining the market value of services and encouraged the Conference to properly define this term to determine health plan payment and dispute resolution. Finally, the revised proposal utilizes an Independent Dispute Resolution process to settle billing disputes. ASPS believes a third-party repository should be used for dispute resolution and proposed that NCOIL amend this portion to utilize a fee schedule based on FAIR Health Inc.

The National Conference of Insurance Legislators is slated to vote on the final proposal this month. Once passed, the model legislation will sunset in five years.

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