State drafts rules to regulate emergency room payments
Patients are often billed by doctors to make up the difference from insurer reimbursements. The so-called balanced billing practice would be banned.
SACRAMENTO -- — Gov. Arnold Schwarzenegger's administration has moved to ban physicians and hospitals from billing patients for the cost of services above what their HMOs are willing to pay.
Such bills, which patient advocates call a consumer abuse, are the product of a protracted feud between insurers and healthcare providers, principally emergency room doctors, radiologists and anesthesiologists.
Those doctors often work in hospitals but don't have contracts with the same health maintenance organizations that serve the hospitals. Believing the reimbursements they receive from insurers are too low, providers send additional bills to patients for the difference. Many patients wrongly assume that bill is the invoice for their co-payment and is authorized by their HMO.
Medical bills: An article in Tuesday's California section about a move to prohibit physicians and hospitals from billing patients for charges above what their HMOs will pay gave the incorrect name for that practice. It is called "balance billing," not "balanced billing."
Thousands of Californians have been paying these bills, even though it is their insurers who are legally responsible for reimbursing providers, consumer advocates said.
"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," said Beth Capell, a lobbyist for Health Access California, a patient advocacy group. "It's just wrong."
"Balanced billing," as the practice is called, is regulated in eight states. But versions of legislation to control it have repeatedly died in Sacramento amid opposition from either providers or insurers.
In 2006, Schwarzenegger ordered his administration's HMO regulators to ban the practice. 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. The state's main doctors' lobby said the new rules, if approved by the department after a public comment period that ends May 12, could backfire by causing physicians to send the entire bill to patients to let them haggle with insurers for repayment.
