There’s a battle brewing in New Jersey around the issue of out-of-network billing by providers. Aetna has sued half a dozen New Jersey providers for alleged gross over-billing of Aetna patients who went out of the insurers network for care. Out-of-network billing is often called balance billing.
"New Jersey is our primary play," Elena Butkus, head of state government affairs at Aetna, told the trade publication Health Leaders Media. "They have the highest charges in the nation."
"They send the big bills,” Butkus said. “The fundamental issue is greed and bad players in certain instances on the hospital-based physician side. Out-of-network physicians in those four specialties charge 300 percent to 400 percent of the Medicare rate."
“Aetna is grossly overstating its case, Lawrence Downs, JD, who serves as CEO of the Medical Society of New Jersey,” told the publication. "If doctors don't sign an oppressive provider agreement, they're considered bad guys… They're labeled a bad actor or a crook by Aetna."
Illinois is seen as a leader in terms of creating regulations on what out-of-network providers can charge patients. The state adopted a balance billing law enacted in 2011 that includes arbitration for balance billing disputes and protections for patients who get their care at an in-network hospital or surgery center. All services delivered at the in-network hospital or surgery center are considered in-network, even if the provider in question is not in fact in the patient’s network.
Like Illinois, Colorado doesn’t allow out-of-network providers to charge patients out-of-network charges if the patient is at an in-network hospital or surgery center. The relevant law in Colorado is CRS 10-16-704, in case you’re in the mood for some light reading on the subject.
Despite some consumer protections in the Affordable Care Act, the out-of-network issue continues to be a thorny and relevant one. We wouldn’t be surprised to see it pop up in the Colorado legislature’s upcoming session.