California Bans Balanced Billing By Health Insurers For Emergency Care

TheCalifornia Department of Managed Health Care on Friday released draftregulations that would bar physicians and hospitals from billing patients forthe cost of services above what their HMOs are willing to pay, the LosAngeles Timesreports. The draft regulations are an attempt by Gov. Arnold Schwarzenegger's(R) administration to ban the practice known as "balanced billing" byphysicians who often work in hospitals but do not have contracts with the sameHMO as the hospital. Some doctors -- who mostly are emergency departmentphysicians, radiologists and anesthesiologists -- believe payments they receivefrom insurers are too low and send bills to patients for the difference,according to the Times. Patients may wrongly assume that the bill is fortheir copayment and is authorized by their HMO.

While "balanced billing" is regulated in eight states, legislation toregulate the practice in Californiahas "repeatedly died" in the state Legislature, according to the Times.State HMO regulators have spent the past two years working on a compromisebetween insurers and providers but were unable to reach an agreement. DMHCDirector Cindy Ehnes said, "We tried to say, when we were young and naive,that we could find a mutually acceptable resolution to make sure physicianswere being paid fairly and on time," adding, "We finally said, 'Wecan't solve this marketplace dispute, but what we can do is our core mission ofprotecting consumers.'"

Under the proposed regulations, Californiahospitals and hospital-based physicians would be barred from billing patientsfor the cost of emergency care that is covered under their health plans. Apublic comment period on the regulations ends May 12. The state Assembly alsois considering legislation (SB 981) that would ban balanced billing and requireHMOs to give physicians an interim payment and establish a method for resolvingdisputes.

The California Medical Association opposes the ban, saying that if theregulations are approved, physicians might send entire hospital bills topatients rather than deal with insurers. In addition, Francisco Silva, generalcounsel for the association, said specialists would be less inclined to be oncall for emergencies if the regulations are approved (Rau, Los AngelesTimes, 4/1).

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