Pennsylvania’s Governor Looks to Protect Consumers from Balance Bills

By: Cohen, Placitella & Roth @ Jun 03, 2016

Consumers are finding out the hard way that not all medical providers working at health facilities in their insurance network are also part of that network.  Surprise bills, also known as balance bills, from out-of-network medical providers have become a rapidly growing concern.  To illustrate, consider a common situation.  You have a medical emergency, say a broken bone that is not life-threatening but requires immediate treatment.  You go to an in-network hospital, pay your co-pay right away, and receive medical care.  Sometime after that, you receive a bill for hundreds, or perhaps thousands, of dollars from the doctor who took care of you – surprise!  And that is when you find out that, although the hospital was in-network, the doctor was not, so your insurance company refuses to pay those charges in full.

The growing balance bill issue

As a Philly.com piece explains, more and more people are being hit with these balance bills in spite of being up to date on their insurance premiums, choosing an in-network facility, and promptly paying their co-pays.  A Consumer’s Union survey found that nearly one third of privately insured Americans have received such bills.  A consumer who does not pay up can face a collection agency, and therefore potential lasting damage to her credit rating.  Balance bills can result not just from an emergency room visit.  Patients who go to an in-network hospital for surgery performed by an in-network surgeon can wind up with an unexpected bill when an anaesthesiologist is not a hospital employee and therefore not in-network.

One factor contributing to the balance bill problem is the growing practice in hospitals of contracting with outside vendors to provide medical staff for emergency rooms.  Frequently, even though a hospital may be within an insurance network, the vendor (and therefore all physicians employed by that vendor) is not.  Hospitals also frequently employ physicians as independent contractors.  According to Philly.com, hospitals considering a doctor’s credentials often do not concern themselves with which insurance networks that doctor belongs to.

What can consumers do to protect themselves from balance bills?  Is it reasonable to expect a patient to vet every professional who might contribute to her care in every hospital situation?  Or is there a better solution?

Pennsylvania’s proposed solution

Pennsylvania Governor Tom Wolf has another idea.  Philly.com reports that Governor Wolf is proposing a new bill that would protect consumers against balance bills.  Wolf’s proposal, found here, would require providers and insurers to reach agreement on out-of-network bills without involving patients.  Providers and insurers would be expected to agree to binding arbitration of billing disputes on a tight timeline under penalty of heavy fines.  The governor’s proposed bill also forbids providers to refer patient bills to collection agencies.  Pennsylvania legislators cautiously suggest that there may be some bipartisan support for the governor’s ideas.

Reach out to a Philadelphia consumer protection firm to learn more

If you are involved in a dispute with your insurance company or a medical provider about unfair billing, the skilled consumer protection attorneys of Cohen, Placitella & Roth, PC, can help.  Call us today at (215) 567-3500 or reach us via our online contact form.