USE CASE: Assessing Out-of-Network Provider Billing

Colorado Medical Society is the largest organization of physicians in Colorado, working to to improve Colorado’s health care environment for physicians and the patients they serve.

Project Summary: The Colorado Medical Society is committed to assessing charge data related to professional services as described under the Colorado Consumer Protection Act in order to facilitate discussions among providers, payers, and consumers, to inform policy changes. The Society has been working to address a series of policy issues regarding provider network adequacy and out of network charges.The goal of the study was to arrive at a mutually agreed upon policy solution to the problem of consumers receiving unexpected bills from out-of-network providers when they receive care at an in-network facility.

Benefit to Colorado: The Society engaged in professional mediation with the Colorado Association of Health Plans (CAHP) in an attempt to come to a consensus on policy recommendations to address these issues. The CO APCD provided a custom data report to help detail the size and scope of the problem of outlier charges by out of network providers in the treatment of patients at in-network facilities. Data from the CO APCD helped to underscore the “data-driven” nature of the Society’s commitment to advocacy and innovation.

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