Measure takes aim at health care billing disputes

Consumers could soon have protections in health care billing disputes if state lawmakers approve a bill introduced in the House this week.

Co-sponsored by a bipartisan group of more than 30 lawmakers, House Bill 1553 would require insurance and health care providers to settle billing disputes through arbitration.

“We’re trying to take the consumer out of the middle of the reimbursement process,” said state Rep. Matthew Baker, a Bradford County Republican, the bill’s main sponsor.

Called the Surprise Balance Bill Protection Act, the bill is similar to one in the Senate introduced by state Sen. Judy Schwank, a Ruscombmanor Township Democrat. Senate Bill 678 last month was referred to the Banking and Insurance Committee, which has elicited stakeholder responses.

Both bills prohibit an out-of-network provider from issuing a surprise bill in excess of the cost-sharing agreement that would have been imposed by an in-network provider.

A balance bill arises when an out-of-network provider charges above what an insurance company has agreed to pay. These providers are often invisible to consumers. It can happen, for example, when a radiologist – who works at a hospital not for one – charges to read a mammogram.

The result for consumers can be big medical bills because there is no negotiated reimbursement rate without a contract between the insurance company and health care provider.

The practice predates the Affordable Care Act and can impact more than preventive care, including ambulances service and emergency room care.

The Reading Eagle first reported on this issue in March 2015.

Jay Mahoney, an agent with Gallen Insurance, brought the issue to the forefront after a number of his clients received $70 bills for mammograms that are supposed to be covered at no additional cost under health care reform to foster early detection. Some of those surprise bills went into collection.

The Cumru Township insurance agent doesn’t get as many balance bill complaints as the half-dozen a week he once did, but the problem, he said, is still far from being solved.

“I think this bill is still very, very important because there’s got to be some protections for consumers,” Mahoney said.

The letter Mahoney wrote to Schwank in 2015 resulted in Pennsylvania Insurance Commissioner Teresa Miller holding a three-hour public hearing in October 2015 that was attended by more than 50 people, including insurance and health care providers.

Miller supports the legislation.

“When patients receive medical care, they and their families should be focusing on getting better, and not worrying about whether a big medical bill will be arriving in the next day’s mail,” Miller said in a statement. “This legislation will go a long way toward making that happen in Pennsylvania.”

State lawmakers said they believed there is wide support for creating consumer protections against balance billing this year.

“This is a serious financial burden when they’re saddled with one of these bills,” Schwank said. “I’m very hopeful that we’ll get to this in the fall.”

Contact Nicole C. Brambila: 610-371-5044 or nbrambila@readingeagle.com.