Health Plans, Providers Gear Up for Battle Over ‘Balance Billing’ Efforts
The California Department of Managed Health Care plans to implement a regulation next month that would classify so-called "balance billing" as an unfair business practice, the Ventura County Star reports.
Oftentimes, balance billing occurs when insured people are treated in hospital emergency departments by doctors who are not included in the patient's health plan's preferred network. Insurers reimburse doctors and hospitals at a lower, out-of-network rate, and the health care providers bill patients for the remainder of the charges.
Under DMHC's rule, state regulators will be able to take enforcement action against physicians or hospitals that engage in balance billing.
California Medical Association President Richard Frankenstein said that CMA would file a lawsuit to challenge the rules the day after they take effect. Frankenstein maintains that health plans need to expand their networks of ED and on-call physicians and pay higher reimbursements.
CMA also opposes balance billing legislation by outgoing Senate President Pro Tempore Don Perata (D-Oakland). The measure would:
- Ban balance billing by ED physicians;
- Establish a process to resolve payment disputes between insurers and ED doctors; and
- Create an interim reimbursement rate for cases in which patients are treated by ED doctors outside of their health plan's network.
Nicole Kasabian Evans of the California Association of Health Plans said that CAHP supports the DMHC regulations but opposes Perata's bill because of concerns that the interim payment rate might be too high.
Jim Lott, executive vice president of the Hospital Association of Southern California, said that prohibiting balance billing would be more helpful if it were part of a larger health care reform effort that expanded health insurance coverage (Kisken, Ventura County Star, 9/12). This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.