Tagged Surprise Bills

Surprise Medical Bill Legislation Takes A Step Forward, But Will It Lead To A Step Back?

The House Energy and Commerce Committee Wednesday approved its version of legislation to curb surprise medical bills.

Though this step was an important advance, there’s still a long way forward before Congress agrees on a legislative solution to this high-profile consumer concern.

These bills, the unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network, have been the hot issue on Capitol Hill for months. Lawmakers on both sides of the aisle have been tripping over themselves to address the widely loathed problem.

One of the existential questions of the debate has been how to compensate health care providers if balance billing — which is what happens when patients are responsible for the costs not covered by their insurer — is prohibited.

The bill before Energy and Commerce originally included what’s known as “benchmarking” to set the payment amount for out-of-network doctors. So, instead of sending patients a bill for the amount that their health plans don’t pay, a doctor would be forced to accept an amount that is the average of what other doctors in the area are paid for the procedure.

This approach has been favored by groups representing employers and insurance plans but draws disdain from medical specialty provider groups. Those doctor organizations, which include specialists like emergency physicians and anesthesiologists, prefer arbitration, sometimes called “independent dispute resolution.” Under that system, both the insurer and provider would propose an amount to an independent third party, who would pick one of the two prices. The loser then pays the costs of the arbitration.

During the panel’s markup, Reps. Raul Ruiz (D-Calif.) and Larry Bucshon (R-Ind.) successfully added an amendment, which would create a “backstop” to the measure’s benchmarking approach.

Here’s how it works: The doctor’s payment would still be based on a benchmark, but if he or she thinks that isn’t high enough, the physician can appeal to an arbitrator. This backstop could be used only if the dollar amount in question is more than $1,250, and the arbitrator can consider only the complexity of the case and the quality of care.

“While I prefer the benchmark like we have in Oregon, I think it strikes a fair and necessary balance,” said the committee’s top Republican, Rep. Greg Walden of Oregon.

Though it’s a tidy compromise between the positions, it means the House bill no longer matches the primary legislation moving through the Senate, which earlier this summer gained the approval of that chamber’s Health, Education, Labor and Pensions (HELP) Committee  That bill exclusively favors benchmarking.

HELP Committee Chairman Lamar Alexander (R-Tenn.) has indicated he’s open to discussions. Other members of the panel, such as Sen. Bill Cassidy (R-La.), applauded the House action.

“The House is taking a step in the right direction,” Cassidy said in an email. “We need to end up in a place that gives patients security while having a level playing field for providers, hospitals and insurers.”

No everyone viewed the “backstop” idea as a positive step forward.

A range of stakeholders who oppose the arbitration approach because they think it will lead to higher costs over time have offered stinging criticism, some even withdrawing their support for the Energy and Commerce measure.

“We have asked Congress for one key assurance — protect us, and our employees, from being locked into government-mandated binding arbitration, which is being pushed by Wall Street-owned doctor groups,” Annette Guarisco Fildes, the CEO of ERIC, a group that represents large employers, said in a statement around five hours before the amendment was introduced in committee.

“Disappointingly, the House Energy and Commerce Committee is set to report out legislation that locks employers into exactly such a mandate,” she added.

Even groups that have been championing the independent dispute resolution approach, like the American College of Emergency Physicians, have qualms with the compromise, saying most emergency services cost less than $1,250 and won’t qualify for arbitration.

That isn’t the only hurdle ahead for the surprise bill legislation.

In the Senate, where the surprise bill provisions are part of a larger package aimed at lowering health care costs across the industry, senators have placed 10 “holds” on the legislation, meaning it can’t go to the Senate floor for a vote yet.

Still, staffers are optimistic that bill can still pass before the Senate leaves D.C. for its August recess.

Did Your Health Plan Deny You Care? Fight Back.

Have you ever stepped up to the pharmacy cash register only to learn your new prescription will cost you hundreds of dollars — instead of your typical $25 copay — because your insurance doesn’t cover it? Or received a painfully high bill for a medical test because your health plan didn’t think it was necessary?

Most people have, but only a tiny fraction ever appeal such decisions. In 2017, for example, enrollees in federally run Affordable Care Act marketplace plans appealed fewer than one-half of 1% of denied medical claims, according to an analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

If you do appeal, your chance of getting the health plan’s decision overturned is a lot better than you might think. “About half of appeals go in favor of the consumer,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a health care consumer advocacy group.

There’s no sugarcoating it, though: Getting to “yes” with your health plan can be an ordeal, and you may need help from friends, family members, your doctor, insurance counselors, even legal aid societies.

In California, health plans are supposed to help facilitate the appeals process. When they deny coverage, they must inform members in writing how to appeal. And when they receive enrollee complaints, they are required to acknowledge them formally, which sets the clock ticking on a series of steps to resolve the dispute.

Unfortunately, insurers don’t always comply with these requirements.

Last month, the Department of Managed Health Care fined Anthem Blue Cross $2.8 million in a settlement covering more than 200 grievance and appeal violations. In some cases, Anthem classified grievances as “inquiries,” which means many enrollees did not get important information about their appeal rights, says Shelley Rouillard, the department’s director.

Mike Bowman, an Anthem Blue Cross spokesman, says the company “is making significant changes in our grievance and appeals process.”

Rouillard says Anthem has had more grievance and appeal violations than other insurers, but “this happens with all the plans.”

Regardless of the type of insurance you have, you can do several things to strengthen your position even before you file an appeal.

For starters, get organized. You will need up-to-date medical records, as well as all communications with your doctor and health plan and any other paperwork that might bolster your case.

“Don’t do anything over the phone. Do everything in writing. You need a paper trail,” says Maria Binchet, offering her hard-earned wisdom from the trenches.

Binchet, a resident of Napa County, has a rarely diagnosed and disabling illness called myalgic encephalomyelitis/chronic fatigue syndrome. Because none of the doctors in her Medicare HMO network has expertise in the disease, she says, she has requested referrals to outside specialists on numerous occasions over the past 22 years, been turned down each time and appealed nine times. After one of those appeals, the health plan allowed her a single visit to a specialist — but he wasn’t taking new patients.

“You have to be persistent and resilient,” she says.

Binchet also advises that you request from customer services the unredacted notes of the health plan’s internal discussion about your case. The notes can help you determine how extensively your case was considered, who made the decision and whether that person was medically qualified to do so.

A letter or phone call from your doctor to the health plan can provide valuable support. “It’s important that you get someone involved who can talk about the medical evidence, because that’s what this is really about,” Fish-Parcham says.

When your paperwork is ready, you must appeal first to your health plan. For most private plans, your deadline for filing the appeal will be 180 days after care is denied. The insurer then faces a deadline — usually 30 days — to render its decision. If it upholds its initial decision or doesn’t meet the deadline, you can take the matter to the agency that regulates the plan within 180 days. If your health is in imminent danger, you can generally get an answer in a matter of days rather than weeks.

Unfortunately, different plans have different regulators, with varying appeal procedures. If you don’t know who regulates your health plan, call customer services and ask.

A large majority of Californians have policies regulated by the Department of Managed Health Care, but millions of others are in plans regulated by other state agencies, such as the California Department of Insurance or the federal government.

A good place to start is the Department of Managed Health Care (888-466-2219 or HealthHelp.ca.gov). Even if it is not your regulator, it can direct you to the right place, Rouillard says.

If you are one of the 26 million Californians in plans regulated by the department, you can request a free review of your case by outside medical experts if your appeal to the health plan failed or was not answered by the deadline.

These independent medical reviews are for cases in which a health plan doesn’t think a type of treatment is medically necessary or refuses to cover it because it is experimental — or won’t pay for emergency medical services after the fact.

An archive on the department’s website (https://wpso.dmhc.ca.gov/imr/) allows you to search past decisions for cases like yours. The summary language in those decisions might help you frame your arguments.

You can also request an independent medical review through the California Department of Insurance (800-927-4357).

If you are one of the 5.5 million Californians in a federally regulated employer plan, your regulator is the U.S. Department of Labor’s Employee Benefits Security Administration (866-444-3272 or www.askebsa.dol.gov).

As you wade through this process, there are organizations that can help.

One of them is the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org), which can assist people in public and private health plans. It offers free advice, can help you get your documents in order and provides legal services.

Medicare enrollees can get free assistance from the Health Insurance Counseling and Advocacy Program (800-434-0222 or cahealthadvocates.org/hicap/).


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Hospitals Block ‘Surprise Billing’ Measure In California

Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.

The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.

Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.

“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.”

Chiu said he and his team would keep working on amendments to the bill that address the concerns of hospitals while maintaining protections for patients.

Hospitals focused their opposition on a provision of the bill that would have limited what they can charge insurers for out-of-network emergency services, criticizing it as an unnecessary form of rate setting.

“Balance billing,” better known as surprise billing, occurs when a patient receives care from a doctor or hospital — or another provider — outside of her insurance plan’s network, and then the doctor or hospital bills the patient for the amount insurance didn’t cover. These bills can soar into the tens of thousands of dollars.

In the absence of federal laws, many states have tried to formulate solutions to balance billing, but health policy experts suggest this issue would be best addressed by the federal government.

Congress is discussing different approaches but not without facing fierce opposition and lobbying from two influential groups: health insurers and providers, including doctors and hospitals.

Last week, the Senate Health, Education, Labor and Pensions Committee passed the Lower Health Care Costs Act, which would require insurers to pay providers no more than the median in-network rate in a geographic region for emergency and nonemergency care. But the American Hospital Association deemed the payment arrangement unworkable.

Getting buy-in from hospitals and other providers will not be easy.

“The system exists in a way that allows a subset of providers to stay out-of-network and charge very high rates,” said Christen Linke Young, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “They’re basically exploiting the system.”

Chiu’s bill would have prohibited out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

The bill also would have limited the amount hospitals could charge insurers for each service, and the amounts would have varied by region.

That’s the part hospitals opposed.

“We’ve said from the beginning that we are supportive of protecting patients. Unfortunately, the proponents of the bill inserted a completely unrelated provision regarding rate setting,” said Jan Emerson-Shea, a spokeswoman for the California Hospital Association.

Emerson-Shea said that if the state sets prices, health plans would have little incentive to negotiate contracts with hospitals. If this provision were removed, the hospital association would support Chiu’s bill, she said.

“That provision doesn’t need to be in the bill if the bill is really about protecting patients,” she said.

Chiu disagrees. Protecting patients from high costs and capping what insurers pay hospitals are “inextricably related,” Chiu said.

If this provision were removed, patients might still face high costs in the form of rising insurance premiums as insurers try to recoup their costs, Chiu said.

“It is useless to protect patients from receiving a bill on the front end if hospitals can turn around and price gouge consumers on the back end. It’s like closing your front door and leaving the back door wide open,” he said.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive nonemergency care.

But millions remain vulnerable to surprise bills, largely because California’s protections don’t cover all insurance plans.

Chiu’s bill was designed to close some of the loopholes. “It is disappointing it couldn’t get done this year” because more Californians will get hit with exorbitant balance bills in the meantime, he said.

The measure was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital, located in his district.

Unlike most large hospitals, San Francisco General does not contract with private insurers. An investigation by Vox found that the hospital considered patients with private insurance out-of-network for emergency care and was slapping many of them with whopping bills. The hospital has since announced it has stopped balance billing patients.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.