Florida, Cal­i­for­nia law­mak­ers tar­get un­ex­pected med­i­cal bills

Modern Healthcare - - NEWS - By Harris Meyer

Florida is poised to be­come the sec­ond big state af­ter New York to shield pa­tients from sur­prise out-of-net­work med­i­cal bills, and Cal­i­for­nia may not be far be­hind if law­mak­ers there can cinch a sim­i­lar deal with physi­cians.

The is­sue has caught fire around the coun­try, with even health pro­fes­sion­als fac­ing the per­sonal ex­pe­ri­ence of un­ex­pected bills for hun­dreds or thou­sands of dol­lars. Con­sumers Union re­ported last year that among peo­ple who had emer­gency de­part­ment vis­its, hos­pi­tal­iza­tions or oper­a­tions in the pre­vi­ous two years, 37% re­ceived a bill for which their health plan paid less than ex­pected. Among those who re­ceived a sur­prise bill, nearly 1 out of 4 got a bill from a doc­tor they did not ex­pect to get a bill from.

Leg­is­la­tors and in­sur­ance of­fi­cials in Ge­or­gia, Hawaii, Mis­souri, New Jersey and Penn­syl­va­nia are study­ing the is­sue or con­sid­er­ing legislation. “It’s not a red or blue is­sue, it’s re­ally bi­par­ti­san,” said Betsy Imholz, spe­cial projects di­rec­tor at Con­sumers Union. “Ev­ery leg­is­la­tor and staffer un­der­stands it and of­ten has been a vic­tim of it.”

Nearly every­one agrees that pa­tients who un­wit­tingly re­ceive ser­vices from out-of-net­work providers at in-net­work fa­cil­i­ties should be pro­tected from these bills. The po­lit­i­cal holdup is de­ter­min­ing how much to pay the out-of-net­work providers. Florida left it up to a to-be-de­vel­oped dis­pute res­o­lu­tion process, while Cal­i­for­nia is still try­ing to solve that is­sue.

Florida’s Repub­li­can-dom­i­nated Leg­is­la­ture passed a bi­par­ti­san bill last month that would pro­tect pa­tients from pay­ing bal­ance bills from out-of-net­work providers in both emer­gency and non-emer­gency sit­u­a­tions. This would ap­ply when the pa­tients go to a health­care fa­cil­ity in their health plan net­work and in­ad­ver­tently re­ceive ser­vices from a non-net­work provider. Pa­tients would only be re­spon­si­ble for pay­ing their usual in-net­work cost-shar­ing.

Plans and non­par­tic­i­pat­ing providers would have to work out pay­ment for those ser­vices through a state-ar­ranged, vol­un­tary dis­put­eres­o­lu­tion process, with a penalty as­sessed to the party re­fus­ing to ac­cept an of­fer that was close to the fi­nal ar­bi­tra­tion or­der. The ne­go­ti­a­tion would be based on the usual and cus­tom­ary rate for the par­tic­u­lar area. Dis­putes could be taken to court. The bill would only ap­ply to PPO-type plans, since Florida al­ready bars bal­ance billing HMO-pa­tients.

Repub­li­can Gov. Rick Scott has un­til April 14 to de­cide whether to sign the bill, which has strong sup­port from the state’s chief fi­nan­cial of­fi­cer. The Florida Med­i­cal As­so­ci­a­tion and other ma­jor stake­holder groups back the bill, though anes­the­si­ol­ogy and ra­di­ol­ogy groups op­pose it. The Florida Hos­pi­tal As­so­ci­a­tion said it agrees “with the gen­eral di­rec­tion of the legislation.” Scott’s of­fice did not re­turn a call for com­ment.

The Florida As­so­ci­a­tion of Health Plans said sur­prise out-of-net­work bills are the No. 1 con­sumer health­care com­plaint. “This is the most com­pre­hen­sive con­sumer pro­tec­tion legislation in the coun­try on (this is­sue), and our as­so­ci­a­tion is proud to sup­port it,” said Au­drey Brown, the as­so­ci­a­tion’s CEO. “The stake­hold­ers came to­gether and agreed to re­move pa­tients from the mid­dle of dis­putes be­tween in­sur­ers and providers.”

Jeff Scott, gen­eral coun­sel of the Florida Med­i­cal As­so­ci­a­tion, said the bill was a com­pro­mise that was ac­cept­able to most physi­cians even though the real prob­lem is that in­sur­ers don’t fully in­form con­sumers what they’re buy­ing.

Mean­while, in Cal­i­for­nia, a broad coali­tion of pay­ers, unions, con­sumer ad­vo­cates and some providers are back­ing a sim­i­lar bi­par­ti­san bill that nearly passed the Leg­is­la­ture late last year and now is be­ing con­sid­ered in amended form. The bill would es­tab­lish a bind­ing, in­de­pen­dent dis­pute-res­o­lu­tion process for in­sur­ers and providers in cases where pa­tients re­ceived care from out-of-net­work providers at in-net­work fa­cil­i­ties. It would ap­ply only to non­emer­gency care, since emer­gency physi­cians are al­ready barred from bal­ance billing pa­tients by a state Supreme Court rul­ing.

But the Cal­i­for­nia Med­i­cal As­so­ci­a­tion strongly op­poses the bill, ar­gu­ing it would hin­der con­sumers’ abil­ity to use their out-of-net­work ben­e­fits and give plans too much lever­age over physi­cians. The CMA did not pro­vide com­ment for this ar­ti­cle.

The Cal­i­for­nia Hos­pi­tal As­so­ci­a­tion is neu­tral on the bill. A CHA spokes­woman said there’s lit­tle hos­pi­tals can do since state law bars them from em­ploy­ing doc­tors or re­quir­ing them to join par­tic­u­lar health plans, plus hos­pi­tals have no way of know­ing when hos­pi­tal-based physi­cian groups will use a non­par­tic­i­pat­ing physi­cian on an on-call ba­sis.

An­thony Wright, ex­ec­u­tive di­rec­tor of Health Ac­cess Cal­i­for­nia, which spon­sored the bill, said the po­lit­i­cal hang-up is that the CMA wants gen­er­ous guar­an­teed pay­ment rates for outof-net­work physi­cians. But pay­ers say those would be higher than mar­ket­based ne­go­ti­ated rates and would drive up costs. Still, he pre­dicted the bill will pass this ses­sion, which ends Aug. 31, be­cause pub­lic pres­sure is mount­ing. “When peo­ple get these bills, it makes every­one look bad, and there’s a com­mon in­ter­est in get­ting this re­solved.”

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