"This is a total giveaway to the HMOs," said Francisco Silva, general counsel for the California Medical Assn. He said specialists will be less inclined to be on call for emergencies.
The Legislature has been struggling with this topic for much of this decade, with lawmakers reluctant to choose sides between two groups of major political donors. This year, the Assembly is considering a bill -- SB 981 from Senate President Pro Tem Don Perata (D-Oakland) -- that would ban balanced billing, require HMOS to give doctors an interim payment and establish a method for resolving disputes, something that is done in Delaware and Florida.
For The Record
Los Angeles Times Wednesday, April 02, 2008 Home Edition Main News Part A Page 2 National Desk 1 inches; 42 words Type of Material: Correction
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."
New Jersey and West Virginia require HMOs to pay the doctors' bills. Maryland has a formula to determine what the reimbursement rate should be. Connecticut, Colorado and Rhode Island indemnify patients against having to pay these bills.
Even lawmakers who are harshly critical of insurers believe that balanced billing is unacceptable.
"It seems clear to me that the contract for payment is between the provider and the insurance company," said Sheila Kuehl (D-Santa Monica), the chairwoman of the Senate Health Committee and author of bills to get rid of private insurers.
In California, many patients are not aware that they are not supposed to pick up the extra tab. Michele Salas, 40, of San Diego, received bills from radiologists who had read her CAT scans at the request of her hospital when she was treated for cancer.
"Depending on whose desk it landed on, some of those specialists were part of my network and others weren't," she said. "They were calling and demanding payment."
Salas said she ultimately paid more than $1,500.
Many doctors say they are simply trying to collect their full rate.
"Our attitude is: Most providers' usual and customary charges are reasonable," said Dr. Myles Riner, an emergency room physician from Greenbrae, Calif., and past president of the state chapter of the American College of Emergency Physicians.
Insurers said that paying doctors and hospitals more than they pay their own providers would disrupt the managed care system, because it would create a disincentive for providers to sign contracts with HMOs.
"We want our members to have good, reliable, predictable service," said Chris Ohman, president of the California Assn. of Health Plans.
But some insurers have paid doctors below their "reasonable and customary" rate -- the legal standard for reimbursements. In 2005, state regulators fined Health Net $250,000 for underpaying emergency room doctors and other physicians in hospitals. The department said the Woodland Hills HMO had underpaid more than 65,000 claims.
--
jordan.rau@latimes.com
