State Supreme Court Ruling Stops Surprise Medical Bills for ER Patients
California Political Desk
January 09, 2009
SACRAMENTO – Over the past two years, 1.76 million Californians who already had healthcare benefits received surprise medical bills following hospital visits, according to a recent APCO Insight Survey. The practice known as balance billing resulted in individual medical bills from $100 and under to upwards of $20,000, and came even though a hospital contracted with the patient's health insurance plan.
The author of legislation to prohibit balance billing, Senator Leland Yee (D-San Francisco/San Mateo), today applauded a ruling by the California Supreme Court yesterday declaring the practice illegal.
"The practice of balance billing is unconscionable and I applaud the Court for ruling in favor of innocent patients," said Yee. "It is unfair for patients to ever be caught in the middle of a payment dispute between insurance companies and doctors. With this predatory practice abolished, consumers will finally be protected."
The Court´s ruling stated, "Emergency room doctors must resolve their differences with HMO´s and not inject patients into the dispute. Interpreting the statutory scheme as a whole, we conclude that the doctors may not bill a patient for emergency services that the HMO is obligated to pay. Balance billing is not permitted."
In September, Governor Arnold Schwarzenegger (R-Los Angeles) signed into law SB 697 authored by Senator Yee to ban balance billing for individuals enrolled in Healthy Families and Access for Infants and Mothers (AIM), programs to provide healthcare coverage for uninsured children and pregnant women of low-income families. The bill officially became law on January 1.
Yee had previously authored legislation to ban balance billing outright, but the bill stalled in committee due to staunch opposition from some emergency room physicians.
Prior to yesterday´s ruling, balance billing most often occurred when a provider sent a bill for an amount that was more than the contracted rate with the patient´s plan or when a non-contracted provider, such as an anesthesiologist, radiologist, pathologist, or emergency room physician, sent a bill for any balance a health plan did not pay.
Due to the practice of balance billing, coverage alone did not necessarily mean that families were left without significant healthcare costs. Non-contracted doctors often over-charged patients relative to the rates that contracted providers accepted. In fact, a recent survey showed non-contracting doctors over-charged Healthy Families recipients between 206 and 1769 percent. The most egregious examples were for an initial hospital inpatient consultation which Medi-Cal reimbursed at $53.92, but the Healthy Families participants were charged on average $966.20 by non-contracted physicians.
A review of complaints made to the California Managed Risk Medical Insurance Board shows that four percent of such complaints received by the board were about balance billing. However, the number is likely significantly higher as individuals may also be reporting complaints to their health plans, Department of Managed Health Care, or may simply pay some or all of the charges without filing a grievance with any entity.
The author of legislation to prohibit balance billing, Senator Leland Yee (D-San Francisco/San Mateo), today applauded a ruling by the California Supreme Court yesterday declaring the practice illegal.
"The practice of balance billing is unconscionable and I applaud the Court for ruling in favor of innocent patients," said Yee. "It is unfair for patients to ever be caught in the middle of a payment dispute between insurance companies and doctors. With this predatory practice abolished, consumers will finally be protected."
The Court´s ruling stated, "Emergency room doctors must resolve their differences with HMO´s and not inject patients into the dispute. Interpreting the statutory scheme as a whole, we conclude that the doctors may not bill a patient for emergency services that the HMO is obligated to pay. Balance billing is not permitted."
In September, Governor Arnold Schwarzenegger (R-Los Angeles) signed into law SB 697 authored by Senator Yee to ban balance billing for individuals enrolled in Healthy Families and Access for Infants and Mothers (AIM), programs to provide healthcare coverage for uninsured children and pregnant women of low-income families. The bill officially became law on January 1.
Yee had previously authored legislation to ban balance billing outright, but the bill stalled in committee due to staunch opposition from some emergency room physicians.
Prior to yesterday´s ruling, balance billing most often occurred when a provider sent a bill for an amount that was more than the contracted rate with the patient´s plan or when a non-contracted provider, such as an anesthesiologist, radiologist, pathologist, or emergency room physician, sent a bill for any balance a health plan did not pay.
Due to the practice of balance billing, coverage alone did not necessarily mean that families were left without significant healthcare costs. Non-contracted doctors often over-charged patients relative to the rates that contracted providers accepted. In fact, a recent survey showed non-contracting doctors over-charged Healthy Families recipients between 206 and 1769 percent. The most egregious examples were for an initial hospital inpatient consultation which Medi-Cal reimbursed at $53.92, but the Healthy Families participants were charged on average $966.20 by non-contracted physicians.
A review of complaints made to the California Managed Risk Medical Insurance Board shows that four percent of such complaints received by the board were about balance billing. However, the number is likely significantly higher as individuals may also be reporting complaints to their health plans, Department of Managed Health Care, or may simply pay some or all of the charges without filing a grievance with any entity.
Print
Share
Email
