Regulation Watch

Zelis Regulatory Efforts, Summer 2017

by Matthew Albright


State Legislatures Wrap Up

In reviewing the activity of the 2017 state legislative sessions, we were particularly interested in bills that affected balance billing, healthcare payments, and provider networks – including requirements on network adequacy and provider directories.

Balance Billing

Out of more than 80 bills on balance billing (or “surprise billing”) that were introduced this year in state legislatures across the county, eight have so far been adopted into law. Laws in Arizona (AZ SB 1441), Texas (TX SB 507), Indiana (IN HB 1273), Louisiana (LA HB 435), Oregon (OR HB 2339), and Maine (ME LD 1557) included provisions that tackled balance bills for patients in non-emergency situations. Thirty states now have provisions on balance billing in emergency situations, twenty-two of which have restrictions on balance billing in non-emergency situations.



Laws passed in Montana (MT SB 44) and North Dakota (ND SB 2231) tackled balance billing specific to charges associated with air ambulances. Previous state attempts at regulating air ambulance bills have been quashed by law suits that have claimed successfully that the Airline Deregulation Act (ADA) prevents states from interfering with fares, routes, and services of aircraft, including fees for air ambulances. Nevertheless, Montana and North Dakota tried to thread the legal needle by mandating requirements that apply to payers and providers, but not directly to the air ambulance companies.

It is also worth noting that Utah (UT SCR 002) and Pennsylvania (PA HR 337) both passed resolutions this year requesting that the federal government re-examine the ADA pre-emption in light of egregious balance billing by air ambulances.

Healthcare Payments

Although a number of states drafted bills that addressed healthcare payments, none of those bills were ultimately passed.

Provider Networks

So far in 2017, two states adopted significant provider network directory laws: Hawaii (HI SB 387) and Maine (ME LD 1557). Hawaii’s law is a broad, network adequacy bill that includes requirements on networks, contracts, and directories, while Maine’s law is focused on directory and balance billing requirements. Smaller laws with provisions concerning provider networks were passed in Colorado (CO HB 1165 and CO SB 88), Connecticut, Texas, and Nevada.

It is likely that Illinois, too, will have a significant network adequacy law: IL HB 311 was passed by both houses and is now on the desk of the governor this year.

Laws, regulations, or sub-regulatory requirements on insurers’ provider directories, specifically, have now been adopted in 29 states, plus the District of Columbia.



Ongoing Internal Compliance

Zelis continually tailors its products to conform with state and federal laws. A great example of this is our coordinated work with payer clients to deliver “the perfect 835” (electronic remittance advice) to providers. Not an easy task! In a staggering example of bureaucracy gone awry, no less than four committees, run by four different public and semi-public organizations/agencies, maintain the various code sets mandated for use in the 835, requiring payers to re-examine their codes at least three times a year for compliance.