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STATE | ASPS Recommendations Adopted in National Model Out of Network Bill

The National Conference of Insurance Legislators (NCOIL), a bipartisan group of state legislators, has been working since the summer to develop a model out-of-network bill that can be replicated in all states across the country faced with "surprise billing." As was report in the November issue of Advocacy Matters, ASPS submitted comments in September and November encouraging the Conference to make updates to their draft model bill. Within the Society's most recent comments, ASPS made numerous recommendations, including a request to ensure that states engage in comprehensive and rigorous determinations of health plan network adequacy; to permit for price transparency measures that allow for unanticipated surgical scenarios without penalizing the provider; and to utilize an Independent Dispute Resolution process to settle billing disputes.

On November 19, NCOIL's Health, Long-Term Care & Retirement Issues Committee voted 14-3 to adopt the Out-of-Network Balance Billing Transparency Model Act. Many of ASPS and specialty medicine's recommendations were incorporated into this final version, such as defining the "usual and customary rate" as 80th percentile of all charges by a provider in the same or similar specialty and in the same geographical area. The model bill further stipulates that the fee schedule must be produced by a benchmarking database maintained by a nonprofit organization that is not financially affiliated with an insurance carrier. This definition is a major achievement and will hopefully set the tone for future definitions of UCR for all out-of-network bills introduced in 2018. Furthermore, the bill strengthened requirements for carriers to audit provider directories and networks monthly, as well as other network adequacy requirements.

ASPS believes that the adoption of this model language by NCOIL is a significant victory for organized medicine, as state legislators often rely on NCOIL model bills when they introduce legislation. Yet the Society recognizes that the Act is not perfect. Instead, it embodies the influence of ASPS and specialty medicine in educating state legislators on this important issue and overcoming the insurance industry's denial of culpability.

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