News October 13, 2015ATLANTA | Imagine arranging for a surgical procedure, following all of the insurance guidelines about an “in-network” doctor and hospital, securing pre-approval, paying the required deductible and co-payment, and then still getting bills from doctors for more money. It’s a common scenario, according to insurance and medical professionals, who call it “balance billing.” It’s when a physician bills the patient for the balance of the fee beyond what insurance paid. Consumer advocates call it surprise billing. In many states, it’s illegal. The Senate Health and Human Services Committee is considering whether to do the same in Georgia, impose other regulations or leave it to the free market. “We have to look at this as a consumer-protection issue and not as an insurance issue, because these patients are getting bills they don’t owe,” said LeeAnne Gasaway, a lobbyist for the America’s Health Insurance Plans, the trade group for insurance carriers. The billing happens because hospitals assign specialists based on their internal arrangements, not insurance networks. So a patient attended by an in-network surgeon in an in-network hospital has no choice over who performs the lab work, reads the X-rays or administers the anesthesia. A 1992 Georgia law allows those doctors to file a claim against the patient’s insurance, which decides what to pay them. But doctors who aren’t satisfied with that payment say they set their fees based on their own overhead, including rent, employees, student loans and other costs. “If a patient receives care from a doctor outside their network, this doctor does not have in-network access to the plan’s covered patients and has no ability to reduce his or her charges based on the promise of more referrals,” said Dr. Todd Williamson, a Gwinnett County neurologist and a former president of the Medical Association of Georgia. He said the problem is that insurance companies keep such narrow provider networks that it’s difficult to avoid a specialist outside of them. Hospital officials say it’s because they can’t keep track of which doctors are in a patient network or not, especially during emergencies. “We don’t know what the insurance is,” said Dr. John Rogers, a Macon emergency-room physician. Sen. Dean Burke, a member of the Senate Health and Human Services Committee and a physician, said, “Even if we see the insurance company on the hospital intake form, we can’t know which of the many plans they are covered by or the hundreds of networks they maintain.” Now that hospitals can be penalized under the Affordable Care Act for patients who relapse and require readmission and for infections, they have more incentive to bring in specialists that they know and trust rather than someone who might be in-network but who rarely practices in that hospital, said Burke, R-Bainbridge. Besides, the balanced bill is usually small in relation to what hospitals charge, Rogers told the senators during a hearing last week. “The amount for an emergency physician is not that large compared to facility bills,” he said. The insurance company might pay an
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