Fall 2018 Issue
Mark P. Hickman
By Mark P. Hickman
Manager of Government Affairs
Commonwealth Strategy Group
What is balance billing?
The term “balance billing” refers to when an out-of-network provider bills a patient for the remaining cost of a service after the patient’s health insurance refuses to cover the entire cost. For example, if a trip to the emergency room costs a total of $1,000 and the health insurance plan will only pay the provider $200, the provider has the ability to bill the patient for the remaining balance of $800.
Common examples of this include the following:
Recently, the term “balance billing” or “surprise billing” has been used more frequently to describe situations that differ from the above example. Some of these potential scenarios include:
While the above scenarios may result in a bill that is surprising to a patient, they are not “balance billing” examples. Regardless, all of these different examples have been rolled into the larger balance billing debate. Unfortunately, and most often, providers appear less favorably because they are the party billing the patient. The focus has been on the provider’s bill, rather than the faulty health insurance product that is not providing adequate coverage.
Has this been addressed in the General Assembly?
In the past ten years, legislation has occasionally been introduced around this issue – ranging from prohibiting the ability to balance bill to requiring providers to disclose to patients when they are out-of-network. The physician community has been able to defeat these bills and the legislature has recognized the importance of providers being fairly paid for their services.
The combination of a changing legislature and increasing healthcare costs to the consumer has resulted in a less favorable environment for providers on this issue in the General Assembly. In 2017, legislation was introduced regarding “assignment of benefits” requiring health plans to reimburse the provider directly when a patient has elected to use that option. While this did not address balance billing, the health plans diverted the entire discussion to the negative effects of balance billing on the consumer. The patient advocacy groups sided with the health plans and strongly opposed the legislation. The bill was easily defeated in committee.
In 2018, legislation was introduced that would have prohibited providers from billing patients for out-of-network ancillary services at a higher rate than the in-network rate. It also would have required the providers to disclose to patients that the ancillary services are out-of-network. The patron of the legislation had received her own large bill for out-of-network lab services and wanted to address it. The physician community was able to convince the patron to not pursue the legislation this session and to allow the stakeholders to work on this issue in the interim.
The General Assembly’s Health Insurance Reform Commission (HIRC) is studying the balance billing issue. At a recent HIRC meeting, legislators who sit on the commission expressed their desire to want to find a solution to this issue. The HIRC will meet again in September and the staff has been asked to propose policy options to address balance billing at this meeting. The Chair of the HIRC has already publicly announced she will carry legislation on balance billing. This is a complex issue that is affecting more and more patients. The changing makeup of the legislature is resulting in a renewed focus on consumer protection. It is safe to expect that several legislators will introduce bills around this issue.
Rizwan Ali, MD, DFAPA
Evelyn Arboleda, MD
Martin Buxton, MD, DLFAPA
Wesley Carter, MD, DLFAPA
Peggy Chatham, MD, MHSA
Douglas Chessen, MD, MBA, DLFAPA
Varun Choudhary, MD, MA, DFAPA
Lawrence Conell, MD, DLFAPA
Steve Cunningham, MD
Leonard Dileo, MD, LFAPA
Gregory Fisher, MD, DFAPA
Adam Kaul, MD, DFAPA
Christopher Kogut, MD, MSW, FAPA
Stuart Kyllo, MD
Meredith Lee, DO, FAPA
Rebecca Lindsay, MD, DLFAPA
Joseph Mason, MD, MSW, DFAPA
Andrew Matz, MD
Kenneth Miller, MD, DLFAPA
Shaheen Mustafa, MD
Dorothy O'Keefe, MD, DFAPA
Ashvin Patel, MD, DLFAPA
John Shemo, MD, DLFAPA
Susan Waller, MD, DFAPA
Brian E. Wood, DO, DFAPA
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