Table 2.

Common issues regarding outstanding bills, client strategies, and policy recommendations

Issue	Definition	Advocacy strategies	State-level policy recommendations
Hospital/provider cost-sharing bills	Bills from hospital or provider such as copayments, coinsurance, deductibles, or facility fees	Verify debt or charges against client’s plan contract. If client is unable to pay: • Help client apply for Hospital Financial Assistance (HFA) • Negotiate with hospital/provider (e.g., find fair market price for service(s) performed, write financial hardship letter, offer lesser lump sum payment, and/or set up a payment plan) • Help Medicare-eligible clients enroll in the Medicare Savings Program	Increase price transparency to help patient avoid high-cost providers.
	Medicare requires members to pay 20% coinsurance for most hospital/medical care.		Standardize provider billing practices and issue only one bill for hospitalizations and procedures
	Clients with commercial insurance have higher cost-sharing than individuals enrolled into public insurance programs like Medicaid, Essential Plan and Child Health Plus		Prohibit providers from holding patients accountable for facility fees unrelated to medical services. Such fees should be negotiated between providers and insurers
Hospital/provider balance bills	Balance billing is when a patient receives a bill for the difference between the amount paid by the health plan and the amount charged for services	Verify hospital/provider has accurate insurance information. Determine if balance billing protections apply, such as: • Members of Medicaid and Qualified Medicaid Beneficiaries in a Medicare Savings program are protected against balance billing. • Hospitals that are part of an HMO network cannot balance bill commercial, fully-insured enrollees. • HAs can help negotiate balance bills if necessary (see above)	Expand balance billing protections to protect patients who receive erroneous information from their provider or plan regarding in-network providers
Hospital out-of-network emergency services bills	Emergency Room bills from out-of-network (OON) providers in an in-network or OON hospital	• If client has a fully-insured commercial plan, they should be held harmless. If the plan does not comply, HA can help the client file a complaint with Department of Financial Services (DFS) • If client has a self-insured commercial plan verify if No Surprises Act protections apply. If not, help client participate in an Independent Dispute Resolution (IDR) • Help clients apply for hospital financial assistance or to negotiate down their medical bills	Prohibit OON billing for emergency services, defined to include all hospital, physician and ambulance charges, and any other pre-emergency services.
			Create an independent dispute resolution process for plans and providers, and prohibit all balance billing for emergency services
Surprise bills	A bill is a surprise bill if: • Bill is from an OON provider at an in-network hospital and either: • in-network doctor was not available; • client did not know an in-network physician provided services; or • unforeseen medical circumstance arose at time services were provided • A client is referred by an in-network provider to an OON provider and client is not aware the provider they were referred to was OON. Only applicable if plan requires referrals	If client has a fully-insured commercial plan, HAs help the client complete and submit an assignment of benefits (AOB) form to be held harmless for the bill	Extend balance billing protections to patients who receive false information about a provider’s inclusion in a network from either the provider or the plan.
		If the plan does not honor the AOB or mistakenly process the AOB as an appeal, file a complaint with DFS	Apply these protections in all instances when patients unknowingly receive care from an out-of-network provider
		If client has a self-insured commercial plan or is uninsured, use same approach as Hospital out-of-network emergency services bills
Hospital/provider bills for non-covered services	All health insurance plans can deny coverage and bill for a service on the grounds that it is “not a covered benefit”, meaning that the service is excluded from the plan’s contract	Verify that the plan is not violating any applicable federal or state laws by failing to cover the service.	Expand coverage for preventative care services to include ultrasounds in lieu of mammograms for women with dense breast tissue.
		Review the plan contract. If the plan is not responsible to cover the service, help client apply for hospital financial assistance or negotiate the bill	Expand coverage of IVF and fertility services and improve dental coverage and benefits
Hospital/provider bills for services denied on medical judgement	Both private and public health insurance plans can deny coverage for services deemed not meeting the plan’s clinical criteria, or if the service is from an OON provider and not materially different from the in-network service	The HA can help the client file an internal and/or external appeal • Fully-insured – Department of Financial Services (DFS) external appeal • Self-insured – Independent Review Organization (IRO) external appeal	Provide robust consumer assistance programs and include contact information for programs on all claim denials
		If the appeal is lost, help the client apply for hospital financial assistance or negotiate the bill	Maintain external appeals databases so that consumer and advocates can review past decisions
Hospital/provider bills for services that need prior authorization	Many insurance plans require prior authorization before they will cover certain medical services or medications. Clients who fail to request prior authorization may be billed for services	Verify the medical service requires prior authorization. A client may be held harmless when an in-network provider fails to obtain prior authorization	Limit the types of care that require pre-authorization. For example, New York State recently prohibited prior authorization for pediatric mental health hospitalizations
		Request that the provider submit prior authorization retroactively. If that is unsuccessful, help the client apply for hospital financial assistance or negotiate the bill	States must provide independent consumer assistance programs to aid patients in navigating prior authorization requirements for care