Ohio Government Update: Price Transparency and Surprise Billing

Ohio Government Update: Price Transparency and Surprise Billing

In July of this year, Governor DeWine vetoed unworkable language that the Ohio Legislature voted to include in the biennial budget bill on price transparency and surprise out of network billing.  Under the problematic language, providers would have been required to make available to patients information that they did not have on healthcare pricing and accept rates for surprise out of network bills for which other entities had negotiated.

After he vetoed those provisions, Governor DeWine issued an Executive Order requiring his administration to adopt or implement rules to address price transparency, surprise medical billing and access to de-identified claims data.  Senator Stephen Huffman, a physician from Tipp City, OH has introduced two bills that the Ohio State Medical Association has agreed to support that approach these issues in a more practical way.

Price Transparency – Senate Bill 97

Senate Bill 97 has already passed the Senate and is awaiting action by the Ohio House of Representatives.  If the bill becomes law, hospitals would be required to publish a list of standard charges on their website. Upon a patient’s request, hospitals would also be required to provide a reasonable, good faith estimate of the cost of each service that is scheduled at least seven (7) days in advance.  The requirement does not apply if an insurance company does not supply necessary information for the estimate within 48 hours of the request.

It is important to note that included with each estimate would be a notification to the patient that a provider’s services will be billed separately from the hospital. There is no requirement in SB 97 that those professional charges be provided to a patient in advance of a procedure at this time.  However, using the budget bill that passed in July as an indicator, there are members in the Ohio House of Representatives that would like to see price transparency throughout the healthcare system.

Surprise Billing – Senate Bill 198

Senator Steve Huffman also introduced Senate Bill 198, which is an improved version of legislation to address requirements related to surprise billing.  The bill generally would prohibit surprise billing at an in-network facility and require an insurance company to pay the provider for the service at the billed rate or enter into negotiations or arbitration regarding the claim.

Senate Bill 198, if it became law, would do the following:

  • Imposes requirements related to billing for unanticipated out-of-network care. 
  • Prohibits providers that provide unanticipated out-of-network care from billing patients for the difference between the amount charged by the provider and the reimbursement proposed by the health plan issuer. 
  • Requires a health plan issuer, within 30 days of receiving a claim for unanticipated out-of-network care, to either pay the provider or enter into negotiations regarding the claim. 
  • Allows, if negotiations are unsuccessful after 60 days, either party to request binding arbitration for claims that exceed $700 or, under certain circumstances, are $700 or less but aggregate to exceed $700. 
  • Requires health plan issuers to issue a directory of health care providers for each plan issued by the issuer. 

If a claim does not meet the $700 threshold required for arbitration, the health plan issuer would be required, at a minimum, to reimburse the provider the lesser of: (1) the provider’s charge; or (2) the 80th percentile of all provider charges in the same or similar specialty for the healthcare service provided in the same geographical area as reported in a benchmarking database.  A company called FairHealth maintains a nationally recognized healthcare benchmarking database.  You can learn more about FairHealth’s methodology here.

Ohio Radiological Society

If you have questions about this legislation or other items of importance to your practice relating to decisions made in Columbus, please contact Contact Rachel Winder, at [email protected] or call 614-223-9316. In addition, as always, please consider a contribution of any amount to the Ohio Radiological Society PAC.