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HBMA Approves New Policy Framework for Unexpected Out-of-Network Medical Bill Legislation

The Board of Directors approved a new policy framework outlining HBMA’s position on federal and state legislative proposals to address unexpected out-of-network medical billing scenarios. The HBMA Policy Framework for “Surprise” Out-of-Network Medical Billing Legislation (Policy Framework) was developed by the HBMA Government Relations Committee and the HBMA Out-of-Network Billing Task Force.

The Policy Framework affirms HBMA’s commitment to protecting patients from unexpected medical bills and points out the role health plans must play to address this important issue.

The Policy Framework defines HBMA’s position on four key aspects related to out-of-network medical billing scenarios: 1. how to define “surprise” billing scenarios; 2. how to protect patients; 3. how to reimburse the OON provider; and 4. how health insurance plans can play a role in preventing “surprise” billing scenarios.

HBMA developed the Policy Framework to help shape any legislation that may be enacted by Congress on out-of-network medical billing scenarios.

[Download Policy Framework]

Additional Background
“Surprise” out-of-network (OON) medical bill scenarios are currently regulated at the state level. Since the end of 2018, the U.S. Congress has been discussing how federal legislation can be used to fill in gaps of state laws and provide protections to patients in states that have not enacted a “surprise” billing law.

The HBMA Government Relations Committee became concerned about proposed federal legislation that would have adversely affected the ability of healthcare providers to negotiate fair network participation terms with health plans. The Government Relations Committee also recognized how the federal proposals overlook how health plans contribute to “surprise” billing scenarios such as with narrow networks, inaccurate provider directories, inaccessible networks, inadequate coverage policies and unreasonable network participation terms.

In January, the HBMA Government Relations Committee created a task force to study federal policy proposals and recommend how HBMA can advocate on this issue on behalf of the healthcare revenue cycle management industry.


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