Even with the best health insurance coverage, consumers are vulnerable to surprise medical bills. Most often, surprise bills are received following an ER visit, when a patient is treated by an out-of-network provider at an in-network facility. As Denver Injury Lawyers, we stay up-to-date on changes in the law that impact our clients. On May 14, 2019, Governor Polis signed into law a bill that prohibits insurance companies from sending balance bills to consumers who unknowingly see an out-of-network provider, either in the context of emergency care or when they seek care at an in-network facility. Doing so will be considered a deceptive trade practice and the state Attorney General has the authority to enforce the law. However, where consumers voluntarily seek out-of-network care, balance billing may still be permitted.
The new law also sets a payment rate for out-of-network providers and facilities, establishes a process to address the collection of out-of-network payments following these scenarios, and requires providers to inform consumers of their rights regarding bills sent by out-of-network providers.
Two Payment Rates Set for Out-of-Network Providers
Under the new law, providers will be paid the greater of 110% of the carrier’s median in-network rate for the same service in the same geographic area or the 60 percentile of the in-network rate for the same service in the same geographic area based on claims from the Colorado All-Payer Claims Database in the prior year. Facilities will be paid the greater of 105% of the carrier’s median in-network rate for the same service in the same geographic area or (2) the median in-network rate for the same service in the same geographic area based on claims from Colorado All-Payer Claims Database in the prior year.
The Law Establishes Process to Address Out-of-Network Payments
The law requires out-of-network providers and facilities to work out the payment with the insurer, leaving the consumer out of the middle, with the exception of any copayment, coinsurance, or the deductible amount the consumer would normally owe pursuant to their coverage. In addition, the Commissioner of Insurance must identify and implement a payment methodology for out-of-network private ambulance companies who transfer patients to a hospital during an emergency that holds consumers harmless.
Patients Must Be Informed of Their Rights
Under the new law, health care providers will be required to provide consistent, accessible information to patients about their rights regarding bills sent by out-of-network providers in both emergency and non-emergency situations.
How Our Denver Personal Injury Lawyers Can Help
If you have any questions about this new law or are considering a medical malpractice lawsuit, we welcome you to contact our skilled Denver personal injury lawyers by email or phone at 303-333-8000 to schedule a free consultation.
