By Holly Hayes
As noted in a previous post (available here) Texas House Bill 2256, signed into law on June 19, 2009, provides a procedure for mediation of out-of-network health benefit claim disputes. The law gives patients the option to mediate when they are ‘balance-billed’ by their insurance company for services provided by out-of-network facility-based physicians like radiologists, pathologists, and neonatologists. ‘Balance billing’ occurs when a physician bills a patient for the difference between what the physician charges for a service and what an insurer pays the physician for that service. When a physician is not in-network for an insurer, there is no contracted payment rate that the physician has agreed to accept from the insurer so the insurer can pay what is deemed appropriate and the patient is billed for the difference.
At the federal level, H.R. 3962, the “Affordable Health Care for America Act” is currently being considered in Congress. The bill defines ‘cost sharing’ (see bottom of page 9) and specifically excludes “premiums, balance billing amounts for non-network providers, or spending for non-covered services.” Although the bill says that out-of-pocket payments are capped for an individual at $5,000 or $10,000 for a family, out-of-network balance billing amounts are not included in those caps. Find out more at the The Wall Street Journal Health Blog (here).
Look for an analysis of how other states are approaching ‘balance billing’ in a future post.
Technorati Tags: Healthcare, ADR, law, mediation
Tags: Balance Billing, Mediation
December 17th, 2009 at 3:36 pm
Holly should have mentioned that the above-stated Federal bill possesses no protection for out-of-network providers when dealing with a health plan. For example, a trauma surgeon bills Aetna $1500.00 for its member being treated for a car wreck. Aetna discovers the provider is out of network and its member is protected under HR 3962. The plan would then drastically underpay the claim at $33.00 expecting little objection.
Layton Lang
December 20th, 2009 at 12:39 pm
There are so many aspects of this plan that the politicians keep overlooking though. The medical industry is wrought with overspending and has gone for too long without any regulation or oversight. Insurance premiums have gone up 138% for a reason and it isn’t simply corporate greed.
Private insurance companies are a part of the problem, yes. When regarding health, private insurance never should have been allowed to be profitable business in the first place. For-profit insurance means requires a need to make money and inevitably that is going to affect the quality of the insurance that people are getting from the company. Companies don’t want to spend money on an individual so they will take whatever measures necessary to ensure they don’t have to. But the medical industry has been profiting all along as well. Procedural costs, visits, even x-rays cost varying amounts state to state, city to city and practitioners are being bounced around by pharmaceutical companies to try and make money while waiting a year or more for the insurance companies to pay up.
This may be why the US was ranked #37 according to the World Health Organization. http://www.ourblook.com/compon...../#catid107
Either health care needs to become a single unit in which there are no privatized barriers, which we may have lost since the rejection of the public option by the Senate, or we find a way to actually bring health care back to a fair free market based standing. The entire industry is wrought with greed from every angle, physicians hiking costs, pharmaceutical companies giving incentives for pushing their products, lobbyists for insurance company interests, and lobbyists for pharmaceutical interests. Where do we draw the line? Health care has had nothing to do with actual care for well beyond two decades.