California Making Another Attempt to Stop Balance Billing

California lawmakers are tackling the problem of balance billing, also known as surprise medical bills.

Health plans have a network of providers and facilities that are ‘preferred’ because the health plans and their designated health care providers and facilities have agreed to accept certain negotiated rates for treatments and procedures.

Whereas one medical plan’s network may be mapped out to look similar to a family tree, the reality is that many health plans, enrolled doctors, unenrolled doctors, state laws, and federal laws all create a mess of twisted vines that sometimes wrap in circles. The patient is often the person trapped in the mess, caught somewhere between wanting to pay the negotiated rate because they went to an in-service facility and being charged an ‘open’ rate because the doctor who treated him was ‘out-of-network’.

Why Did California Address the Issue of Balance Billing?

Few people who have been in near-fatal car accidents, suffered from life-threatening strokes, or are otherwise severely injured are able to take the time to ask the ambulance driver if the hospital around the corner is within their healthcare network. Knowing this, California enacted Health & Safety Code § 1371.4, which was added to the Knox Keene Act. As a result, any payers with plans regulated by the Department of Managed Care were required to pay providers for emergency care even if the providers were not contracted.

In 2016, California added a new law, A.B. 72, which also was supposed to stop the number of surprise medical bills received by patients. If a patient visits an in-network facility, but is treated by an out-of-network provider, the law ensures the health plan will make provisional payments to the out-of-network provider, who should receive the average contracted rate from the health plan.

California’s Newest Attempt to Tackle Balance Billing

California lawmakers are hoping A.B. 1611 helps stop many types of balance billing. The proposed legislation would stop hospitals from charging insured patients beyond the in-network cost-sharing total for emergency room care and any needed post-stabilization health care. Even if an individual is treated by an out-of-network doctor at an out-of-network hospital for emergency services, the bill should not go beyond the cost of the patient’s own insurance copayment or deductible.

If passed, A.B. 1611 would affect any health plan contract written or any insurance policy issued, amended, or renewed on or after Jan. 1, 2020.

In some cases, even patients who have declined to receive treatment at an emergency room have reportedly received surprise medical bills. In a recent Vox article, a New Jersey woman named Jessica fell and received a laceration to her ear. The ER gave her an ice pack, but she said she wasn’t otherwise treated. Jessica received a bill for $5,751. Reporter Sarah Kliff found that most of these high ER bills are attributed to an ER facility fee, which she compared to a cover charge at a bar because it’s a fee that is charged just because you walked through the door.

According to a report by NPR, even if you go to a physician’s group office, such as a suite that houses five G.I. specialists who call themselves, for example, “The G.I. Experts of Southern Arizona,” you can’t be sure they all take the same insurance. If the doctor you normally see is booked, but another doctor has availability, always ask whether that other doctor takes your insurance. In many of these joint practices, each doctor has his or her own contracts with different insurance companies.

Join a Free Surprise Medical Bill Class Action Lawsuit Investigation

If you were hit with a surprise medical bill from an out-of-network doctor at an in-network hospital, you may be entitled to compensation.

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This article is not legal advice. It is presented 
for informational purposes only.