There is growing concern about the financial burden of balance billing, or surprise billing, on individuals with private health insurance plans. Idaho has limited provisions concerning balance billing, but none that protect patients who are unaware they are receiving services outside their insurance carrier’s network. Idaho residents receiving emergency care or major surgeries often do not choose their treating physicians, putting them at risk of being charged staggering amounts for out-of-network services. Research shows that balance billing disparities exist between geographic areas and service type which may point to private health insurance network inadequacies.
Half of states have full or partial protections for patients experiencing balance billing situations and legislation is currently being considered by Congress. The purpose of this report is to examine balance billing in Idaho. This study analyzes claims data provided by Idaho’s major insurance carriers and a survey of physicians throughout the state. The findings confirm Idaho experiences similar trends in balance billing as other states. The results of this study could provide indication of overall network adequacy. The report concludes:
- In Idaho, roughly 1% of claims for Idaho residents are out-of-network. This figure jumps to over 2% for emergency out-of-network services.
- The results show there are noticeable differences in rates of out-of-network claims based on region, urban/rural designation and service type.
- In general, emergency service claims are more likely to be out-of-network compared to overall claims, a finding that is largely consistent when the data is broken down by region, urban/rural designation and service type.
- Rural counties tend to have higher rates of out-of-network claims overall, but urban areas have more issues with emergency services being out-of-network.
- Although some physicians indicate they balance bill patients, qualitative responses reveal some insurance carriers and physicians are willing to work with patients who are at risk of being balance billed.
- Actions taken to curb balance billing include engaging in case-by-case negotiations for out-of-network claims, offering income-based rates to ease the financial burden on patients and providing patients with referrals to other physicians.
Larsen, Benjamin; May, Matthew; Kim, Cheong; and Crossgrove Fry, Vanessa, "Balance Building in Idaho 2019" (2019). Idaho Policy Institute Reports. 14.