End of surprise out-of-network billing in CA

[photoguy]

Just heard that California passed AB 72 which eliminates surprise billing from an out-of-network provider at an in network facility:

Audio: Measure to prevent 'surprise' medical bills heads to Gov. Brown | 89.3 KPCC

https://ww2.kqed.org/stateofhealth/...to-end-surprise-out-of-network-medical-bills/

I believe Jerry brown still needs to sign it

Bill text:

https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB72

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2017, to provide that if an enrollee or insured receives covered services from a contracting health facility, as defined, at which, or as a result of which, the enrollee or insured receives covered services provided by a noncontracting individual health professional, as defined, the enrollee or insured would be required to pay the noncontracting individual health professional only the same cost sharing required if the services were provided by a contracting individual health professional, which would be referred to as the “in-network cost-sharing amount.” The bill would prohibit an enrollee or insured from owing the noncontracting individual health professional at the contracting health facility more than the in-network cost-sharing amount if the noncontracting individual health professional receives reimbursement for services provided to the enrollee or insured at a contracting health facility from the health care service plan or health insurer.

This seems like a huge deal to me.

 

[growing_older]

About time. How soon can we get that passed elsewhere?

 

[MildlyEccentric]

According to the Consumers Union web page on the topic, 4 states have passed legislation already and over 20 more are working on some sort of legislation.

 

[Salty]

Does anyone know if Pennsylvania has any type of a similar law?


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[MBSC]

Does anyone know if Pennsylvania has any type of a similar law?

PA does not currently have this. According to the link in Mildly's post above you need to follow the status of this bill in the PA Senate. Bill Information - Senate Bill 1158; Regular Session 2015-2016 - PA General Assembly

 

[Salty]

Thanks MBSC !


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[travelover]

I wish there was a web page where one could post the names of these out of network traps, like speed traps of old.

For example, a hospital that has no in network anesthetists. It might publicly shame them into doing the right thing.

 

[EastWest Gal]

Does anyone know if Pennsylvania has any type of a similar law?


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Not at this time. I skimmed through a thoughtful article on the subject, which discusses the few states that have addressed the issue thus far.

http://www.insurance.pa.gov/Documents/Balance Billing/Kevin Lucia.pdf

Legislation has been proposed and minimally discussed within the last year but it hasn't gone anywhere yet.




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[Turtle]

According to the Consumers Union web page on the topic, 4 states have passed legislation already and over 20 more are working on some sort of legislation.

I hope you will all take time to go to the Consumer Union link and sign the petition to support their advocacy and education on it. It's shocking to see how easily it can happen to us. Be sure to scroll down to find the link to your state's info!

 

[GTFan]

I wish there was a web page where one could post the names of these out of network traps, like speed traps of old.

For example, a hospital that has no in network anesthetists. It might publicly shame them into doing the right thing.

Some insurers are working with hospitals to avoid these surprise bills. When my wife broke her leg last year we got lucky and ambulance took us to a hospital that was in-network for Humana. No surprise that the anesthesiologist for the surgery was not, but Humana covered it because they had a deal with the hospital for common services that you don't have choice over to be covered.

I do agree that this is something that needs to be enacted nationwide, of course that will never happen.

 

[FIYes]

We experienced this when DH was taken by ambulance to the ER for a cardiac issue. The hospital was in network, the docs he saw when he was in the hospital for a couple of nights were in network. However one of the ER docs was out of network. Our insurance company went to bat for us on this and got the bill reduced. We have a fairly high deductible policy so much of this episode was out of pocket.


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[MBSC]

Self-funded employer plans will be exempt from the California law.

 

[Texas Proud]

I wish there was a web page where one could post the names of these out of network traps, like speed traps of old.

For example, a hospital that has no in network anesthetists. It might publicly shame them into doing the right thing.

I was thinking the same thing.... as most anesthetists are not in network...


But, I think there is a work around... agree with the facility a price for service even if there are none in network working there... then the law would limit how much they could charge....

 

[Cobra9777]

DW had surgery recently at an in-network hospital with her in-network doctor. I called the hospital ahead of time and inquired about this. They said they try to ensure that all ancillary services are provided by in-network professionals. But in cases where that can't be accomplished, the hospital has an agreement with all individual providers that they will bill at the patient's in-network rate.

I was pleasantly surprised by that. Turns out she did have some out-of-network services provided, but they all billed at the network rate. This is not required in Texas, so it's nice to see some facilities implementing this policy.

I agree this reform needs to be enacted in all states or possibly at the national level. We've been caught by this in the past, but fortunately it's never been more than a couple hundred dollars.

 

[Helena]

.

For an acute medical emergency diagnosis, most PPO-type insurance plans will pay out-of-network providers network benefits for the first 48 hours. Since out-of-network providers are under no contractual obligation to accept the PPO allowable amount... in an emergency situation, their services are allowed in full then paid at the network benefit. That would make the insured responsible for a higher coinsurance amount [usually 20%]... because it would be 20% of the billed amount vs 20% of the PPO's contractual allowable.

.

 

[explanade]

I wish there was a web page where one could post the names of these out of network traps, like speed traps of old.

For example, a hospital that has no in network anesthetists. It might publicly shame them into doing the right thing.

Is it the hospitals or the anesthesiologist and other out-of-network providers?

I heard in some cases these providers are holdouts for higher reimbursement rates before they would sign up to be in network.

And then they just do "drive bys" like pop into your hospital room after surgery and then they bill you or go into the operating room while you're unconscious.

I don't know how they've been able to get away with such practices. It's like people who are drunk or unconscious being taken advantage of.

 

[Texas Proud]

Is it the hospitals or the anesthesiologist and other out-of-network providers?

I heard in some cases these providers are holdouts for higher reimbursement rates before they would sign up to be in network.

And then they just do "drive bys" like pop into your hospital room after surgery and then they bill you or go into the operating room while you're unconscious.

I don't know how they've been able to get away with such practices. It's like people who are drunk or unconscious being taken advantage of.

I will give you one worse... had the anesthesiologist for my DWs surgery... came by in the prep room and talked to her etc. etc... the operation took a total of less than 5 minutes (I know because from the time they rolled her out of the prep room to the Dr. talking to me was 5 minutes)...

The bill comes in for TWO people at about 1 hour each (cannot remember... might have been 45 minutes...)... but the bill huge.... and out of network... I told them I would not pay for 2 people nor for the amount of time they listed as the max he did anything for DW was 15 minutes.... I paid $900 something...

 

[explanade]

So did that amount include something for the out of network guy?

 

[MooreBonds]

I will give you one worse... had the anesthesiologist for my DWs surgery... came by in the prep room and talked to her etc. etc... the operation took a total of less than 5 minutes (I know because from the time they rolled her out of the prep room to the Dr. talking to me was 5 minutes)...

The bill comes in for TWO people at about 1 hour each (cannot remember... might have been 45 minutes...)... but the bill huge.... and out of network... I told them I would not pay for 2 people nor for the amount of time they listed as the max he did anything for DW was 15 minutes.... I paid $900 something...

In all fairness, it's similar to a service repair technician like a plumber, or any hourly professional who may have non-constant employment (lawyer, etc.). Is it fair for the plumber to spend an hour driving to your house to spend 15 minutes unclogging a toilet, and only billing you a small amount? Then driving 45 minutes to their next service call, only to bill them for 15-30 minutes at a 'low' rate? Or a lawyer who doesn't have people lined up out the door, just waiting their turn to give him 3,000 billable hours per year?

The anesthesiologist is prepping for their caseload beforehand. They look at the patient's chart. They do research and calculations for which anesthesiology to administer and in what dose, etc. Then afterwards, they chart, make notes, etc.. It's not like they're a line cook, moving straight down the line from one entree to the next, and in 1 hour's time have 4 different surgeries knocked out without any prep/other non-billable time.

 

[travelover]

In all fairness, it's similar to a service repair technician like a plumber, or any hourly professional who may have non-constant employment (lawyer, etc.). Is it fair for the plumber to spend an hour driving to your house to spend 15 minutes unclogging a toilet, and only billing you a small amount? Then driving 45 minutes to their next service call, only to bill them for 15-30 minutes at a 'low' rate? Or a lawyer who doesn't have people lined up out the door, just waiting their turn to give him 3,000 billable hours per year?

The anesthesiologist is prepping for their caseload beforehand. They look at the patient's chart. They do research and calculations for which anesthesiology to administer and in what dose, etc. Then afterwards, they chart, make notes, etc.. It's not like they're a line cook, moving straight down the line from one entree to the next, and in 1 hour's time have 4 different surgeries knocked out without any prep/other non-billable time.

I see your point, but the guy paid $900 for 5 minutes work. I know people, smart educated people, that don't make $900 a day.

 

[RobbieB]

But if the anesthesiologist makes a mistake you're dead. And that's his job by the way, keeping you just this side of death.

 

[travelover]

But if the anesthesiologist makes a mistake you're dead. And that's his job by the way, keeping you just this side of death.

By that logic, ambulance drivers should be able to charge you anything they want, because they are, after all, potentially saving your life.


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[Texas Proud]

In all fairness, it's similar to a service repair technician like a plumber, or any hourly professional who may have non-constant employment (lawyer, etc.). Is it fair for the plumber to spend an hour driving to your house to spend 15 minutes unclogging a toilet, and only billing you a small amount? Then driving 45 minutes to their next service call, only to bill them for 15-30 minutes at a 'low' rate? Or a lawyer who doesn't have people lined up out the door, just waiting their turn to give him 3,000 billable hours per year?

The anesthesiologist is prepping for their caseload beforehand. They look at the patient's chart. They do research and calculations for which anesthesiology to administer and in what dose, etc. Then afterwards, they chart, make notes, etc.. It's not like they're a line cook, moving straight down the line from one entree to the next, and in 1 hour's time have 4 different surgeries knocked out without any prep/other non-billable time.

Not quite.... from what I know from my sister (who used to be a surgery nurse), they have them stacked up one after another.... IOW, there is no drive time to slow them down... maybe you know someone who was different, but I doubt that any of them goes into a hospital with just ONE surgery to do....

Also, most plumbers etc. have a fixed rate no matter where you live... if they are next door and come to your house it is the same rate as if they had to drive 45 minutes....

 

[RobbieB]

The ambulance ride costs $500 after insurance. For a drive across the parking lot. Rehab to hospital, can't be more than a couple hundred feet. I know, I paid it.

 

[travelover]

The ambulance ride costs $500 after insurance. For a drive across the parking lot. Rehab to hospital, can't be more than a couple hundred feet. I know, I paid it.

Sure, but what if the ambulance was responding to a serious heart attack at your home. Don't you think those attendants deserve $100K each to save your life?