Pennsylvania insurance commissioner latest to propose protection from surprise balance bills
Pennsylvania Insurance Commissioner Teresa Miller was the latest state official to propose protections for healthcare consumers against surprise balance bills, when she announced new measures on Tuesday.
Surprise balance bills occur when a consumer receives emergency care, or has made a good-faith effort to use providers and facilities in their insurance network, but unexpectedly receives a service from an out-of-network provider or facility, then receives a bill.
The goal of Miller's proposal is to take consumers out of billing disputes between insurers and providers. Her department is looking to work collaboratively with the General Assembly, consumers, and stakeholder groups to draft legislation on the issue.
Her plan would protect consumers who seek healthcare at in-network facilities, or from in-network providers, from being billed by an out-of-network provider at a cost more than what they would owe to a provider for any in-network cost sharing under the consumer's health plan.
For example, if a consumer's health insurance plan has a $50 co-pay for a certain service delivered by an in-network provider, that consumer would not be liable for more than $50 for that same service from an out-of-network provider.
"At a public hearing in October, I heard from consumers who, despite their best efforts to use providers in their health insurance network, still received out-of-network bills that were in the hundreds -- and in some cases, thousands -- of dollars," said Miller.
It's a common problem, at least according to the Consumer Reports National Research Center. In March 2015, the organization polled more than 2,000 consumers online and found 37 percent had received a bill toward which their insurance plan paid less than expected. One quarter of those surprises came from a doctor they did not realize was out of their network.
There is some precedent for Miller's plan. On April 1, 2015, a law took effect in New York which protects patients from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.
Under the New York Law, when consumers get surprise bills, they need to complete an "assignment of benefits" form that allows the provider to pursue payment from the health plan, and then send the form and the bill to their plan and provider. As long as they've taken that step, they won't be responsible for any charges beyond their regular in-network cost sharing.
The law also sets up an independent dispute resolution process for providers and health plans to settle on a fee for emergency services or surprise bills. The independent reviewers consider provider experience and training, case complexity, patient characteristics and usual and customary charges in making a determination, which is binding.
The Pennsylvania proposal would provide several options for insurers and providers to reach agreement on payment, and if they can't, the matter would go to arbitration. Both sides would submit their offers with supporting documentation, and the arbitrator's decision would be binding.
In no case would the consumer be liable for anything beyond the cost-sharing due for the service if it had been rendered by an in-network provider.
Miller said the open comment process, which will be held October 1, 2016 from 10am to 1pm, will allow her department to get input from various stakeholders, including insurers, hospitals, and health care providers. These key players also testified at the Insurance Department's public hearing on this topic in October. Written testimony can also be emailed to the Insurance Department's Consumer Liaison.
Twitter: @JELagasse
