Balance Billing by Health Care Providers: Assessing Consumer Protections Across States

Area of Science:

• Healthcare policy
• Consumer protection law
• Health insurance regulation

Background:

• Consumers expect in-network care to be fully covered beyond cost-sharing.
• Unexpected balance bills arise from out-of-network providers in emergency departments or in-network hospitals.
• Lack of federal balance billing protections necessitates state-level action.

Purpose of the Study:

• To assess the scope and effectiveness of state laws addressing consumer balance billing.
• To identify gaps in existing state-level consumer protections against surprise medical bills.

Main Methods:

• Comprehensive analysis of state statutes and regulations concerning balance billing.
• Qualitative interviews with key officials in eight representative states.

Main Results:

• A majority of states lack direct protections against balance billing for emergency or in-network hospital care.
• Only 21 states have enacted some form of balance billing protection.
• Just six states offer comprehensive safeguards covering both emergency and in-network settings, with remaining gaps.

Conclusions:

• State-level legislation is crucial for immediate consumer protection against balance billing.
• Federal solutions may be challenging, positioning states as primary protectors in the short term.
• Gaps in current state laws highlight the need for more robust and comprehensive consumer safeguards.