Susan J. Demas
Accidents and emergencies can happen to anyone, and that also puts people at risk of receiving “surprise medical bills” afterwards.
State Rep. Roger Hauck (R-Mt. Pleasant), explains that “surprise medical billing” is just a disagreement between the insurer and a care provider caused by a patient going to an in-network facility for either emergency care or an elective surgery and then receives a “surprise” out-of-network medical bill for care they thought would be covered by insurance.
As previously reported by the Advance, there has been legislation introduced in Michigan to regulate charges from non-participating (or out-of-network) health care providers. House Bill 4459, which was introduced by Hauck, focuses on protecting patients in emergency situations.
HB 4459 states that if an insured person didn’t have the chance to choose an in-network provider for a medical service, or if the only provider available to perform that service was out-of-network, that non-participating provider would have to accept 150% of Medicare (or the average in-network amount; whichever is higher) as payment in full.
Providers also would be prohibited from attempting to collect any more money, unless the patient owed fees for coinsurance, co-payment or deductibles — or else face an administrative fine.
“I think everyone is in agreement that the patients need to be protected from this practice and taken out of the middle,” said Hauck.
He added that if there’s any potential for a patient to receive an out-of-network bill, they should be informed in a reasonable time frame. Hauck said the tricky part is how to reconcile out-of-network billing issues after the patient is protected from the financial impact that can result from narrow networks, retroactive denials and cost-shifting trends within health insurance plans.
“What we don’t want to do is create a structure that pays out-of-network doctors more than in-network doctors. That could lead to more doctors deciding to be out-of-network. At the same time, we have to ensure that doctors are paid at a fair rate,” said Hauck.
House Bill 4460, introduced by state Rep. Frank Liberati (D-Allen Park) in 2019, aims to protect patients seeking non-emergency medical care.
Both HB 4459 and HB 4460 were voted out of the House Health Policy Committee in November and then referred to the Ways and Means Committee. If they pass from the second panel, the bills will go before the full House. The next stop would be the state Senate.
HB 4460 states that when there’s advance notice given to an out-of-network provider, that entity could only bill the patient for what their health insurance doesn’t cover if the patient consents in writing at least 14 days prior to the procedure, or during the pre-surgical consultation – whichever is earlier.
Within that written disclosure, the out-of-network provider would be required to give a good-faith estimate of the cost. They also would need to advise the patient of their right to arrange for services to be provided at a lower cost by an in-network provider. House Bill 4460 was referred to the Committee on Ways and Means in November 2019.
Physicians for Fair Coverage, a Washington, D.C.-based advocacy group is also focused on ending the surprise insurance gap as it relates to in-network and out-of-network facilities and care providers.
During a phone interview last week with the Advance, Physicians for Fair Coverage CEO Michele Kimball explained that insurance gaps are getting bigger because insurance companies are narrowing their provider networks and lowering physician reimbursements.
Kimball said that even if a person does their homework about an elective surgery, or if they are getting emergency treatment, they may not have control over all aspects of their visit and have no way to tell if the anesthesiologist or physician treating them is in-network.
“A patient may have done everything right, and done all of their homework, but maybe not accounted for one particular type of care, like anesthesia, or not be able to check on the provider if they’re having an emergency,” said Kimball.
Hauck said the two primary solutions to resolving surprise medical bills that are being debated on Michigan are a benchmark rate and health care arbitration. A benchmark is a plan that each state designates as the standard for essential health benefits. Health care arbitration is a way of resolving health insurance billing disputes outside of court related to health claims that aren’t covered by insurance.
“In Michigan, lawmakers decided on a benchmark rate that is the average in-network rate or 150% of Medicare — whichever is higher,” said Hauck.
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