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What the "balance billing" court ruling means....
Friday, January 09, 2009
As my colleague Anthony Wright said, and which has been trumpeted in front-page headlines around the state today, the ruling in the Prospect case is a big win for consumers---and it is particularly sweet since it was a unanimous and conclusive decision in a case that might well have led to murky law, as did the appellate case that it overturned. Here is what the California Supreme Court said: For HMO members, it is always clear in advance who has to provide emergency services — any emergency room doctor to whom the member goes in an emergency — and who has to pay for those services — the HMO. The conflict arises when there is no advance agreement between the emergency room doctors and the HMO regarding the amount of the required payment… The resolution of such disputes can create difficult problems.
But the question of how to resolve disputes between the doctors and the HMO over the amount due for emergency care is not before us in this case. The issue here is narrow, although quite important for emergency room doctors, HMO’s, and their members: When the HMO submits a payment lower than the amount billed, can the emergency room doctors directly bill the patient for the difference between the bill submitted and the payment received — i.e., engage in the practice called “balance billing”?
Interpreting the applicable statutory scheme as a whole — primarily the Knox-Keene Health Care Service Plan Act of 1975, Health and Safety Code section 1340 et seq. (Knox-Keene Act) — we conclude that billing disputes over emergency medical care must be resolved solely between the emergency room doctors, who are entitled to a reasonable payment for their services, and the HMO, which is obligated to make that payment. A patient who is a member of an HMO may not be injected into the dispute. Emergency room doctors may not bill the patient for the disputed amount.
Often legal decisions are a tangle of precedents and legal Latin (literally) that take a bit of thinking to untangle. Not so in this ruling. Justice Ming Chin, writing a 7-0 decision, chose to use very plain English, and his colleagues concurred. How did the Supreme Court arrive at this decision? How did they find the law so plain when others have struggled to sort out what the law is on balance billing? Well, they did what courts do: they looked at the statutes that have been enacted in sequential order and said here is what the statutory scheme is: The only reasonable interpretation of a statutory scheme that (1) intends to transfer the financial risk of health care from patients to providers; (2) requires emergency care patients to agree to pay for the services or to supply insurance information; (3) requires HMO’s to pay doctors for emergency services rendered to their subscribers; (4) prohibits balance billing when the HMO, and not the patient, is contractually required to pay; (5) requires adoption of mechanisms to resolve billing disputes between emergency room doctors and HMO’s; and (6) permits emergency room doctors to sue HMO’s directly to resolve billing disputes, is that emergency room doctors may not bill patients directly for amounts in dispute. Emergency room doctors must resolve their differences with HMO’s and not inject patients into the dispute. Interpreting the statutory scheme as a whole, we conclude that the doctors may not bill a patient for emergency services that the HMO is obligated to pay. Balance billing is not permitted. Among the key statutes, the Court cites is one of our victories in HMO Reform: the California law that states that the HMO must pay for emergency care if a consumer reasonably believed they had an emergency. While we have been most pleased with this because it is a more consumer-friendly standard than the “prudent layperson” standard used in other states, the law has also been clear that HMOs must pay providers for emergency care they provided so long as the consumer “reasonably” thought they had an emergency. One of the things that we have learned as we have struggled with legislative and regulatory solutions to the balance billing question over the last five years is that HMOs have obeyed the law--- that is, the HMOs actually do pay emergency room providers and in a reasonably timely way. What the ER docs and hospitals are upset about is that they want to get paid more. So the ER docs and some hospitals have gone after the patient to get the money---or to get the patient to complain to the HMO so the HMO will pay more. This is what Health Access opposes because it puts consumers with insurance in the middle of a business dispute between two institutional players that play this game every day while the average consumer goes to the emergency room once in a blue moon and has no idea what hit them when they start getting collection notices. You may be thinking, but wait, that nice emergency doctor, they deserve to get paid. That’s right. The emergency doctor (and the hospital with the emergency room) do deserve to get paid and to get paid timely and to get paid a fair amount. But as the Court pointed out, there are mechanisms for that in the law. And more importantly, ER docs bill HMOs every day—and HMOs pay ER docs. There are literally hundreds of thousands of claims made, and paid, every year in California. When was the last time you went to the emergency room? Thank goodness, it has been several years since I helped a loved one through an ER visit. And he never did figure out all the bills and the paperwork. Consumers should not have their credit ruined just because they did the right thing and got medical care when they needed it most urgently. There were lots of other arguments and issues that could easily have tangled up the Court, making for a murky decision---implied contracts, delegation of the HMO role, legislative efforts, and the regulation on balance billing which is also being litigated. The Court was distracted by none of this. So it is a sweet victory, and sweeter because it is unanimous and conclusive. There is other pending litigation in this area. We shall see what the Court and the various parties do as a result of this ruling. This ruling technically applies only to doctors and not to hospitals, but it is difficult to see the Court reaching any other conclusion with respect to hospitals. And it only applies to emergency care. Going to the emergency room is never a happy experience. But the only thing you should be worrying about if you have insurance is getting better—not the fear that your credit will be ruined. That is what we thought the law should say. And now the Supreme Court has said that is what the law says. Labels: BalanceBilling
posted by Beth Capell |
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10:11 AM
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Victory at the Supreme Court!
Thursday, January 08, 2009
Big consumer victory today. The California Supreme Court ruled 7-0 to protect patients from unfair bills during disputes between insurers and providers. This unanimous ruling by California Supreme Court in Prospect Medical Group vs. Northridge Medical Center, is clear and unequivocal. The case states directly, that when there's a billing dispute between an emergency room doctors and an HMO, "a patient who is a member of an HMO may not be injected into the dispute. Emergency room doctors may not bill the patient for the disputed amount."After years of contentious fights through legislation and regulations, this is big news. As Health Access California has always contended, insured consumers should not have their credit and financial future ruined by unfair double billing. This ruling will prevent patients from being held hostage in a billing war between doctors and health plans. We appreciate the court's decisive ruling to protect premium-paying patients from being unfairly billed and sent to collections and worse. Labels: BalanceBilling
posted by Anthony Wright |
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6:43 PM
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Victory on balance billing...
Wednesday, December 03, 2008
It's official. We now have a final ruling by Sacramento Superior Court Judge Michael Kenny in California Medical Association (CMA) et al. v. California Department of Managed Health Care and Cindy Ehnes, upholding the DMHC’s recent regulations to protect consumers from balance billing for emergency services. We went into the details in a previous post, but it's good news for consumers, so they (and their credit history and financial futures) are not held hostage in billing disputes between insurers and providers. Labels: BalanceBilling, DMHC
posted by Anthony Wright |
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11:37 PM
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Progress on Balance Billing!
Friday, November 21, 2008
It is ironic, on the day Health Access celebrated its founding 20 years ago, a founding that started out of a consumer victory against the California Medical Association (CMA) and other providers, we get word of a new victory in a fight that has Health Access on one side and doctors on the other. The big news: A court sent out its preliminary decision against CMA and other providers, denying their efforts to stop new regulations on “balanced billing” at the Department of Managed Health Insured patients can breathe easier that if they get needed care in an emergency situation, they will not be billed unnecessarily and used as a pawn in a contractual dispute between insurers and providers. The practice of balanced billing, where insured patients are sent the bill when a provider has a billing dispute with the insurer, is a significant problem for consumers. Patients get sent to collections, and have their entire credit history ruined---when legally they owe nothing and have done nothing wrong, except get the care they need. We are pleased the courts sided with the Department of Managed Health Care (DMHC), and against the CMA’s lawsuit. There’s more work to do on this subject, but this is good news for patients. Two final notes on the ruling, from my colleague and legislative advocate, Beth Capell: * First, it is evident from the court’s ruling that the case made by the California Medical Association, the California Hospital Association and other providers ignored the economic impact on consumers and focused only on the economic impact on providers. While it is reasonable for provider trade associations to represent their members, we are weary of these same organizations claiming that they care deeply for consumers when they oppose consumer measures time and again... it is plain that their pocketbooks are their primary concern.
* Second, the court’s ruling rests on the plain language of the law which states that a “unfair billing pattern” means engaging in a demonstrable and unjust pattern of nbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.
Put simply, DMHC defined balance billing as an “unfair billing pattern”, the court found that the law permits it to do so and the providers are squawking because they thought “unfair billing pattern” only applied to provider-plan disputes with consumers as collateral damage. Here’s excerpts from the case, below: The following shall constitute the Court's tentative ruling on the Petition for Writ of Mandate and Complaint for Declaratory and Injunctive Relief filed by Petitioners California Medical Association, California Hospital Association, California Chapter of the American College of Emergency Physicians, California Orthopeadic Association, California Radiological Society, and California Society of Anesthesiologists, set for hearing in Department 31 on Friday, November 21, 2008 at 9:00 a.m. II. Background
This case challenges DMHC’s promulgation of 28 CCR § 1300.71.39 (the “Balance Billing Regulation”). The Balance Billing Regulation was enacted under the authority purportedly granted to DMHC by provisions in the Knox-Keene Act, Health and Safety Code §§ 1340 et seq., in which the Legislature delegated certain regulatory authority with regard to health care service plans (“HMOs”) to DMHC. Of particular interest here is Health and Safety Code § 1371.39, which was added to the Act as part of Assembly Bill 1455 (Scott, 2000). Among other things, § 1371.39 allows HMOs to report “instances in which the plan believes a provider is engaging in an unfair billing pattern” to DMHC.
The Balance Billing Regulation defines “unfair billing pattern” to include a practice known as “balance billing” when that practice is engaged in with respect to emergency care recipients who are enrollees in a health care service plan (an “HMO”). Balance billing occurs when a provider receives less than the total amount billed from a patient’s HMO and subsequently bills the unpaid balance directly to the patient. The Balance Billing Regulation provides:
(a) Except for services subject to the requirements of Section 1367.11 of the Act, “unfair billing pattern” includes the practice, by a provider of emergency services, including but not limited to hospitals and hospital-based physicians such as radiologists, pathologists, anesthesiologists, and on-call specialists, of billing an enrollee of a health care service plan for amounts owed to the provider by the health care service plan or its capitated provider for the provision of emergency services....Petitioners contend that DMHC acted unlawfully in promulgating the Balance Billing Regulation and seek a writ of mandate (under CCP § 1085) ordering DMHC to repeal the Balance Billing Regulation, a declaration that the Balance Billing Regulation is invalid, and an injunction stopping DMHC from implementing and enforcing the Balance Billing Regulation.
...III. Analysis
A. Standard of Review.
...
In reviewing the legality of a regulation adopted pursuant to a delegation of legislative authority, the Court’s inquiry is limited to three questions: (1) whether the regulation is within the agency’s delegated authority; (2) whether the regulation is reasonably necessary to effectuate and not in conflict with the purposes of the statute being implemented; and (3) whether the regulation was promulgated pursuant to proper procedure. (Moore v. Cal. State Bd. of Accountancy (1992) 2 Cal.4th 999, 1014-15; Cal. Gov’t Code §§ 11342.1, 11342.2, 11350(b).) The Court accords the regulation a strong presumption of regularity, and Petitioners bear the burden of showing its invalidity. (Moore, 2 Cal.4th at 1014-15; Credit Ins. Gen’l Agents Ass’n v. Payne (1976) 16 Cal.3d 651, 657.)
...
B. Discussion.
Petitioners challenge the Balance Billing Regulation under each of the three areas of Court review listed above, and additionally challenge the regulation as unconstitutionally vague. Petitioners’ many arguments can be organized into the following categories: (1) that the regulation was not within DMHC’s delegated authority to enact; (2) that DMHC did not follow proper procedures under the California Administrative Procedure Act in promulgating the regulation because its economic impact statement conflicts with substantial record evidence; (3) that the record lacks substantial evidence that the Balance Billing Regulation was reasonably necessary to effectuate the statutory purpose; (4) that the regulation conflicts with the Knox-Keene Act’s purpose that contracts between HMOs and providers be “fair and reasonable to ensure adequate networks”; and (5) that the regulation violates due process because it is overly vague. The Court will address each category of argument in turn.
...* The DMHC Acted Within Its Delegated Authority in Promulgating the Balance Billing Regulation....
a. Health and Safety Code § 1371.39(b)(1) Plainly Authorizes DMHC to Define Unfair Billing Practices....
b. Health and Safety Code § 1371.39(b)(1) Authorizes DMHC to Regulate Providers With Regard to Unfair Billing Practices.
c. DMHC’s Determination that Balance Billing Can Constitute a Billing Pattern is Reasonable..
* The DMHC’s Economic Impact Statement Does Not Conflict with Substantial Record Evidence.
* The DMHC’s Conclusion that the Balance Billing Regulation Was Reasonably Necessary Is Supported by Substantial Evidence.
* The Balance Billing Regulation Does Not Conflict with the Knox-Keene Act’s Requirements for HMO-Provider Contracts.
* The Balance Billing Regulation Is Not Unconstitutionally Vague.
IV. Disposition
..
The petition is denied. The requests for declaratory and injunctive relief are denied. DMHC, as the prevailing party, is directed to prepare a formal order, incorporating the Court's ruling herein verbatim or attaching it as an Exhibit, and a judgment consistent with the ruling; submit them to opposing counsel for approval as to form; and thereafter submit them to the Court for signature and entry of judgment in accordance with Rules of Court 3.1312 and 3.1590.
Labels: BalanceBilling, DMHC
posted by Anthony Wright |
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7:37 AM
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Credit where credit is due to protect credit...
Tuesday, October 14, 2008
The California Department of Managed Health Care implements new regulations tomorrow to prevent "balanced billing," good first steps to protect patients. When insured patients find themselves going to an emergency room or ER doctor that is not contracted with their health plan, there is sometimes a dispute between the provider and the insurer about what the payment should be. The problem is that the patient is then sometimes used as a pawn in these billing disputes. The patient, who pays their premiums and is doing everything right, gets the bills for the disputed--or whole--amount, which also gets sent to collections and court. So patients have their credit and their financial future ruined. The last few weeks have proved the essential importance of credit in today's economy, and the practices of some providers have created a crisis for many California families. As Lisa Girion at the Los Angeles Times reports, there is significant opposition from health care providers to these regulations. There's a real need to resolve these provider-insurer disputes, fairly. Health Access California and other consumer groups supported SB921(Perata), a compromise measure to help resolve these differences, but the Governor vetoed it. The regulations focus on the appropriate role of the agency, which is consumer protection: making balance billing an unfair billing practice, subject to civil penalties and "cease-and-desist" court actions. Nevertheless, these regulations are a good first step... but more work is needed. Labels: BalanceBilling, DMHC
posted by Anthony Wright |
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11:08 PM
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Key bills move to the next step...
Thursday, August 07, 2008
Assembly Appropriations Committee, chaired by Assemblyman Mark Leno, is meeting as we speak. Here's some of the bill that are being passed, and are heading to their second floor vote: * SB840(Kuehl), to establish a single-payer universal health care system, and set up a commission to work out the financing, was passed, with amendments to adjust timing issues. Other bills passed include: * SB973(Simitian) to facilitate county-based public health insurers to work together; * SB981(Perata) to prevent balance billing; * SB1198(Kuehl) to require insurers to offer coverage of durable medical equipment; * SB1440(Kuehl) to require a minimum level of premium dollars to go to patient care; * SB1522(Steinberg) to provide standards for individual insurance products; More information to come... Labels: BalanceBilling, Insurers, Legislation, SB840, Underinsurance
posted by Anthony Wright |
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3:10 PM
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Balancing act...
Saturday, August 02, 2008
Well, it's not a balanced budget deal, but there's some progress on balance billing. Yesterday, the Department of Managed Health Care (DMHC) issued regulations to the Office of Administrative Law on the contentious issue of "balance billing." The new regulations would restrict the practice of emergency health providers sending the bill to *insured* patients if they are having a dispute with their insurer. The OAL will provide a legal review of the regulations before putting them in full effect. The patient--and their credit rating and financial future--should not be used as a pawn in these reimbursment disputes between insurers and providers. The regulations restrict this "balance billing" by making it an unfair billing practice, thus allowing DMHC enforcement actions against those providers who engage in activities that unfairly burden consumers. It's a good step. There is also pending legislation, by Sen. Pres. Perata, Assemblywoman Salas, and others, that would go broader, and look to help resolve these disputes between providers and insurers in the first place. But the first principle is to do no harm--to the patient, or their pocketbook. Labels: BalanceBilling, DMHC
posted by Anthony Wright |
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3:30 PM
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Guest blog on balanced billing from a veteran health advocate...
Friday, May 16, 2008
Beth Capell, Health Access' contract lobbyist extraordinaire, has been advocating for consumers for more than two decades. She offers these thoughts on balance billing, an insidious practice of some doctors and hospitals who decide to threaten insured consumers with aggressive collection agency if the consumer does not pay the “balance” between the insurer or HMO paid for their care and what the doctor or hospital wanted to be paid. (Relatedly, we blogged on a recent and egregious example of the Prime/Kaiser situation. 5/17 UPDATE: There's a new development, where a legal injunction has been ordered, as reported in the Orange County Register on balance billing. The LA Times also has a story.) “Balance” billing has been illegal for Medicare and Medicaid enrollees for decades. It is illegal for HMO enrollees if they go to a contract facility. And until a few years ago, we probably would have said balance billing was illegal when an insured consumer got emergency care, even at a non-contract hospital.
As consumers, we are sympathetic to doctors and hospitals who feel badly treated by HMOs and insurers. We know what that’s like. But as consumer representatives, we are pretty impatient with doctors and hospitals that treat consumers badly. We don’t like that either. And when it is all about a billing dispute between providers and plans, we say a pox on both their houses: get consumers out of the middle.
Well, this week DMHC had a hearing on a regulation to do just that: to say that if a consumer with coverage regulated by DMHC gets emergency care, then the consumer is only responsible for applicable copays or deductible, not for the difference between what the emergency doctor or the hospital wanted to be paid and what the HMO paid. Health Access is fortunate that our representative at this hearing is Elizabeth Abbott, who formerly headed the federal Centers for Medicare and Medicaid Services (CMS) in the western region of the United States: she has heard plenty of plan-provider disputes in her day and has no surfeit of patience with whining. She reports that doctors are furious at the proposed regulation.
As we said, we are sympathetic to doctors and hospitals fighting with HMOs. And indeed we as well as the Department have spent endless hours listening to the complaining of doctors and hospitals.
After all that, we know several things: first, consumers deserve to be protected from bad behavior by doctors and hospitals as well as HMOs and insurers. Second, under California law, doctors and hospitals that do not have a contract with the consumer’s HMO do in fact get paid and usually get paid in a reasonable period of time (less than 60 days). So what are the doctors and hospitals fighting with the HMOs about? It turns out it is not just about the amount of the payment but also what counts how.
You would think that it would be easy to decide that when an ER doc takes care of you because you have a broken bone, he should be paid for reading the x-ray or MRI, but it turns out whether that is part of the bundle of services or not is part of what providers and plans fight over. And they fight over it partly because there is no standardization of bundling. The docs, not surprisingly, want the bundling system the docs have developed (called the AMA/CPT code, if you care). But Medicare decided a long time ago that letting the docs set the rules by which they are paid does not make much sense and ditto with Medi-Cal.
And we made it lots more complicated in California when we allowed the development of the “delegated medical model”. (If your eyes are crossing, welcome to my world.) That means that Blue Shield does not just contract with individual docs, but instead contracts with Sutter Medical Group or Hill Physicians or Beaver or Scripps or some other outfit with thousands of docs and hundreds of thousands of patients. So if you are a Sutter Medical Group patient but you end up at UC Davis emergency room because that is where the ambulance took you, what are the rules for bundling the claim? Is that thing-y they put on your finger to check your blood oxygen in or out of the bundle? Is it the Medicare rules? The Sutter group rules? The Blue Shield rules? Or are you actually HealthNet? And why do you care? Well, probably you will when the ER doc or the hospital loses their
patience with the HMO and just decides to send you to collections and let you
fight it out with the HMO.
And yes, this is yet another way in which our current system piles on administrative overhead for no good reason. So in addition to fighting to prohibit balance billing of consumers, we are trying to help figure out how to minimize the provider-plan disputes by supporting a single set of rules for bundling as well as other changes.
The need to end balance billing got a lot more obvious this week when we found out that one hospital system in Southern California, Prime Healthcare, had sent over 6,000 Kaiser members to collections because Kaiser would not pay whatever Prime Healthcare wanted to charge for their emergency care. Prime Healthcare is a system that refuses to contract with most insurers---so it is not just Kaiser members who are at risk: it is anyone with insurance who walks into their emergency room. It looks as if Prime Healthcare took on Kaiser first but nothing prevents the hospitals from doing the same thing to consumers covered by other insurers that Prime fails to contract with. And Prime also seems to be engaged in the same old game that for-profit Tenet used to play of turbo-charging the charges for care so that the sticker price goes up and up.
As well as the proposed regulations, we are working on AB1203 (Salas) and SB981 (Perata) to prevent balance billing of patients who get emergency care. While both these bills are still in progress, we hope this year we can get consumers out of the middle of these provider-plan disputes.
Labels: BalanceBilling, Hospitals, Insurers, Schwarzenegger
posted by Hanh Kim Quach |
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4:53 PM
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The timing could not have been better...
Friday, May 09, 2008
Dr. Prem Reddy, owner of Prime Healthcare Services, is running around terrorizing 6,000 Southern California Kaiser Permanente members -- sending them enormous hospital bills (via an aggressive collection agencies) and telling them to pay up, or ruin their credit. See the story here. One patient featured is being asked to pay $50,739.70 in full by June.
The company, with 9 hospitals Southern California, is demanding payment for emergency services that are currently under dispute with Kaiser. The patients are being told they must come up with the money to pay for their treatment (the portion that Kaiser is disputing and has not agreed to pay).
The tactic being used by the hospital chain is called "balance billing,'' where patients are asked to pay the difference between what the hospital billed, and what the insurance company paid. The Schwarzenegger Administration has been working on regulations to ban this practice, and in a strongly worded notice releasing their proposed rules, accused providers -- such as hospitals and physicians -- who engage in this behavior of using "innocent enrollees'' as "bargaining chips in an unfair provider billing pattern'' that leads to "long-term harm o the enrollee's health, safety and financial stability.''
Coincidentally -- the Administration's Department of Managed Health Care will hold a hearing on this very issue in Irvine on Wednesday, the heart of Orange County where three of Prime's hospitals are located (and presumeably many of the recipients of these giant bills.) Testimony anyone? (Relatedly, AB1203 by Mary Salas would ban this practice.) Labels: Affordability, BalanceBilling, Hospitals
posted by Hanh Kim Quach |
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12:56 PM
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Balancing priorities on balanced billing...
Tuesday, April 01, 2008
The practice of balanced billing gets the spotlight in an excellent article by Jordan Rau in the Los Angeles Times today. It deserves attention not just in California but across the country. The piece focuses on the new regulations by the Department of Managed Health Care to ban the practice of "balanced billing," where *insured* consumers are unfairly billed and even sent to collections for going to the doctor or hospital. The bill should go to the insurer, but because there's a dispute between the health provider and the insurer, the provider also bills the patien--the whole bill or the "balance" of what the insurer won't pay--as a way to leverage the insurer to pay more. The patient, as a result, either unwittingly pays an bill (often inflated beyond what anybody pays) that is the insurer's responsibility, and even if they don't, they are dragged into this contractual dispute and could be sent to collections--with their credit history and financial future at risk. Either way, it's not what the consumer was expecting when they signed up for health insurance in the first place. As our Health Access California colleague Beth Capell is quoted, "Consumers who do the right thing and go to a hospital that's in their network should not be leveraged in a fight between doctors and insurers... It's just wrong." But in deference to our policy advocate, the quote of note comes from the Administration, which illustrates how contentious this issue, describing how regulatory efforts to broker a deal failed after the Schwarzenegger Administration had issued an executive order on this issue in 2005. The Department of Managed Health Care spent the last two years trying to negotiate a compromise between insurers and providers to work out their payment differences, but couldn't find common ground. So the department decided to simply outlaw the practice through new draft regulations issued Friday.
"We tried to say, when we were young and naive, that we could find a mutually acceptable resolution to make sure physicians were being paid fairly and on time," said Cindy Ehnes, the department's director. "We finally said, we can't solve this marketplace dispute, but what we can do is our core mission of protecting consumers."
The draft regulations would prohibit hospitals and hospital-based physicians from billing a patient for the cost of emergency services that are the responsibility of the patient's health plan. There will continue to be pending legislation, including by Senate President Pro Tem Don Perata, to see if there is a legislative agreement to settling the contract wars between providers and insurers. There are issues to work out: these are often cases where a patient goes to an in-network hospital, but has no idea that the ER doctor on call, or the anasthesiologist or other specialists, are not contracted with their insurer. Unlike contracted doctors, there's no negotiated agreement on the rate. The doctor, who was not in a position to refuse the patient, feels the insurer is underpaying. The insurer isn't going to pay the full billed amount by the doctor--a "sticker price" that is more than any insurer pays. So when there isn't an agreement up front, what should be the payment? There's lots of alternatives--and that's what the various legislative proposals seek to address--but the answer shouldn't be to simply stick the consumer with the bill. But while we are working through those issues, it is appropriate for the Department to focus on what should be the consensus item; to focus on the core issue of protecting consumers from this unfair billing behavior. Labels: BalanceBilling, DMHC, Legislation
posted by Anthony Wright |
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6:51 PM
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Corrective Action and Balance Billing
Friday, March 28, 2008
Now that's responsive. After a nearly seven-hour hearing yesterday in which the Department of Managed Health Care's consumer-protection creds were questioned, the Department has come out swinging (not that kind) on behalf of consumers. The DMHC today released draft regulations on balance billing -- that practice where consumers get a bill directly from the doctor or hospital for the difference of what is/was/will be paid by the insurance company, and what they charge. This is particularly pervasive in emergency situations where patients are unable to "shop around'' and ensure that the provider they are being driven to is "in-network.'' The language to describe this practice is kind of edgy -- as edgy as one can be in a " Notice of Rulemaking Action.'' From the document: "Innocent enrollees are routinely leveraged as bargaining chips in an unfair
provider billing pattern, which can lead to detrimental health care decisions by
the enrollee and aggressive collection activities by the provider, with
long-term harm to the enrollee's health, safety, and financial stability.'' Right on. There's more. "..Providers use unfair and oppressive tactics, holding enrollees as virtual
financial hostages, to pressure health plans to pay their full-billed charges,
irrespective of whether their full-billed charges do, in fact, reflect the
reasonable and customary value of the treatment provided.'' This is a fantastic opening position for advocates to be in on this issue. The comment period for these regulations ends May 12 at 5 p.m, so get letters in! Labels: BalanceBilling, Schwarzenegger
posted by Hanh Kim Quach |
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3:30 PM
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