Pennsylvania’s Insurance Department is proposing new rules to protect patients against “surprise balance” bills.
The bills occur when a patient gets care at a place that’s covered by insurance, but a doctor involved in the care is out-of-network, leading to unexpected charges.
The fees can range anywhere from $10 to $28,000.
“It often takes consumers several months of writing letters and making phone calls to get these out-of-network amounts reduced or waived,” said Chuck Bell, with the patient advocacy group Consumers Union. “And, in about half the cases, they’re not able to and they have to pay an unexpected bill.”
Pennsylvania officials have received complaints about it and are now out with a proposal that, according to state Insurance Commissioner Teresa Miller, would shield patients from paying the extra amount when they did everything they could to stay in network.
“The consumer in this case would not receive any type of balance bill,” said Miller. “Then it would be up to the insurance provider to settle any dispute about what is owed to that out-of-network provider.”
The rules are “constructive and bold,” said Bell, but getting doctors and insurers to sign off on something that would require them to move into a binding arbitration process to settle disputes may be tricky.
“They’re basically in an argument over income here,” said Bell. “So all other things being equal, providers would like to have a higher income, and insurance companies would like to limit the amount they’d have to pay for certain expenses and procedures. So there’s a tug of war going on there.”
It took years to enact similar legislation in New York, while New Jersey lawmakers tabled a bill last year.
“Well, that’s why we’re doing this comment period, to be honest,” said Miller.
Her department is now seeking public comment on the 19-page proposal through the end of next month.
It came out of a hearing last fall, where doctor, patient and insurance groups weighed in on the issue.
“What we heard from everybody is this is a problem we should solve,” she said.
Now, moving forward, figuring out the details of the “how” may be the challenge.
The goal, Miller said, is to have a bill with legislative support by the summer.