|Date:||February 15, 2017|
Health-care consumers who havebeen stung by surprise medical bills mightsoon find some relief from an unexpectedsource: the Arizona Legislature.
The problem occurs when a consumerseeks care after checkingto be sure a doctor, clinic or hospital is part of their insurance company's network — only to be billed later by out-of-network providers such as anesthesiologists or surgical assistantswho were part of the chain of care.
That can sometimes result in a whoppingmedical tab, with theconsumer caught between aninsurance company that doesn't want to pay moreand amedical provider who refuses to accept less.
"Quite frankly, this has happened to several people I know," said Sen. Debbie Lesko, R-Peoria, sponsor of Senate Bill 1441.
Lesko said she sponsored the measure, advanced Wednesdayby the Senate Finance Committee bya 7-0 vote, after a constituent complainedabout just such an experience. Her husband also received a surprise medical bill years ago from an out-of-network anesthesiologist at an in-network medical facility.
SB 1441 would assign an arbitrator to settle disputes if a consumer visits an in-network facility and gets billsof $1,000 or more from out-of-networkmedical providers.
The consumer would contact the Arizona Department of Insurance to request an arbitrator be appointed. The insurer and health-careprovider would first attempt to settle the dispute through an informal conference, which would advance to arbitration if the two sides could not agreeto an amount. The insurer and health-care provider would split the costs of arbitration. Either party would have the right to appeal an arbitrator's decision to the countySuperior Court.
Lesko said she initially sought to assign three benchmark payment rates for each disputed service, allowing the medical provider to choose a benchmark rate they would accept. But medical groups objected and suggested Texas' balance-billing legislation as a model.
In Texas, 94 percent of cases are settled after a phone call between the insurer and medical provider, with only 6 percent of cases decided by arbitration, Lesko said.
Despite the Senate Finance Committee's unanimous "do pass" recommendation, lawmakers,doctors and insurers acknowledge the bill is a work in progress that could be modified through legislative stakeholder meetings.
Blue Cross Blue Shield of Arizona and insurance-industry groups favor the legislation. Multiple doctors' groups and the Health System Alliance of Arizona, which consists of the four largest hospital systems in metro Phoenix, oppose the bill.
"It is a little too weighted on the physician to be the source of the solution," said PeteWertheim, executive director of the Arizona Osteopathic Medical Association. "We want to share in the solution, but we don't want to be the only remedy for this."
“It is a little too weighted on the physician to be the source of the solution. We want to share in the solution, but we don't want to be the only remedy for this.”
Pete Wertheim, executive director of the Arizona Osteopathic Medical Association
The doctors' groups favoraddressing otherfactors such as the insurers' adoption of "narrow networks" that aim to lower insurance costs by limiting provider networks. The doctors' groups also contend insurancecompanies should be responsible for maintaining accurate lists with up-to-date information on in-network providers for different insurance plans.
Representatives of the medical groups said they recognized the need to address the problem, but they also worriedthe legislative bill could have unintended consequences. Doctors, for example, could becomereluctant to take after-hours calls to care for patients at hospitals.
The bill also would restrict the practice of "balance billing" — charging a consumer for the amount beyond what an insurance company agrees to pay. In order to collect a balance for non-emergency care, the bill would require doctors to disclose that they had no contract with the patient's insurer and provide an estimated billing amount before providing care.
Consumers often complain about receiving such bills at in-network hospitals from emergency-medicine doctors, anesthesiologists or other providers who aren't part of their insurance plans. Several states includingColorado, Connecticut, Florida, Illinois, Indiana and Texashave passed legislation limiting out-of-network billing.
On Wednesday, several Arizona lawmakers shared the experiences of family members or friends hit with surprise medical bills.
Sen. Karen Fann, R-Prescott, who contributed language to the bill, said she had a recent procedure performed at a hospital. During a follow-up visit, her doctor was ill, so she was referred to another doctor for a chat that lasted five minutes. She did not learn the doctor was out of her insurance plan's network until she got a $400 bill.
TheArizona Republic reported last year that the Arizona Center for Hand Surgery used a collection agency to sue more than one dozen patients after collecting payments from insurers that were less than the full amount sought by the medical practice.
Lesko said her goal is to protect patients.
"If a patient has done everything in their power to make sure that all the doctors and the facility are covered by their insurance and then they receive a surprise bill from a doctor that was out of their insurance network, is unfair to the patient," Lesko said.