November 3, 2009 © Health News Florida
It was, simply, an emergency.
When Lisa Grehn was in labor at Miami Baptist Hospital two years ago, her obstetrician asked a colleague for assistance. Grehn learned only later – when she got a bill for almost $3,000 -- that the second doctor wasn’t part of her health plan.
That’s an example of the kind of “balance billing” that Florida’s Insurance Consumer Advocate, Sean Shaw, wants the Legislature to ban next session. This week, as committees meet at the Capitol, he’ll be looking for lawmakers willing to sponsor it.
“We want to just outlaw it, basically, take the consumer out of the fight between the insurance companies and the health care providers,” Shaw said.
But getting rid of balance-billing won’t be easy, because doctors will resist fiercely. They don’t want to be told they have to accept less money than they want.
Balance-billing typically occurs when specialists that don’t participate in insurance networks treat patients in hospitals that do. When the insurer pays the specialists only its usual amount, the specialists go after the patient for the rest.
And the patients get stuck with bills that are a big surprise – in many cases, incurred while they were unconscious.
Federal law bars balance billing of Medicare and Medicaid patients, so balance- billing is a problem for those in private health plans.
Shaw is stepping into a broadening national dispute. In January, the California State Supreme Court banned balance-billing entirely.
However, doctors have won some battles. Early this year, the American Medical Association and others reached a $350-million settlement with UnitedHealth Group over what the AMA contended were low out-of-network payments. New York Attorney General Andrew Cuomo agreed to work with UnitedHealth to find appropriate out-of-network payment rates.
In Florida, it is already illegal to balance-bill HMO patients like Lisa Grehn, but the law has no teeth. HMOs may be fined an unspecified amount for balanced billing, Shaw said; he wants to change that to “will,” although he has not worked out the details.
Most of the complaints have come from members of preferred-provider organizations (PPOs), so that’s where Shaw wants to focus. “I think we have to go with the biggest problem right now,” he said.
He has the backing of the insurance industry, which says it would strengthen networks and protect patients. “They shouldn’t have to be financially ruined because they have to pay thousands of dollars in balance-bills through no fault of their own,” said Bob Lotane, director of communications for the Florida Association of Insurance and Financial Advisors.
But Lotane predicted physicians will fight any such measure as fiercely as they battled insurers last year over Senate Bill 1122, which ordered insurers to pay doctors directly when they treat patients who have chosen to go out of network. Doctors won that fight.
An effort to ban balance-billing “would be 1122 on steroids,” Lotane said.
Florida Medical Association does indeed oppose such a bill, said General Counsel Jeff Scott: “If Sean Shaw tells me, as an out of network physician, that I have to accept (in-network payments), I’d say, ‘I’m not going to see those patients.’”
Consumer Advocate Shaw’s reaction: “I think that tells me who cares for the patient and who doesn’t.”
Balance-billing presents patients the choice of paying a great deal of money they don’t feel they really owe, or getting stuck in a ping-pong match between the insurer and the physician’s billing clerk.
Grehn spent four months calling and writing the state Department of Insurance to keep from paying the balance of the doctor’s bill, until, in May 2008, the debt was written off. At one point, she got a letter that said if she didn’t pay in fifteen days, the dispute would be “forwarded to the credit bureau and processed for legal action and a judgment may follow.”
“I was thinking, ‘Do I need to get a lawyer?’” Grehn said. One bill collector suggested that she sue her HMO to force it to pay the doctor.
“I don’t know what he was thinking,” she said.