Judge Upholds California Regulations Against Balance Billing

Ruzanna Harutyunyan's picture

Sacramento, Calif., Superior Court Judge Michael Kenny on Tuesday upheld the regulations issued by the state Department of Managed Health Care that seek to protect patients from "balance billing," a practice often used by hospitals in reimbursement disputes with health insurers, the Sacramento Bee reports.

Balance billing most often occurs when patients with health insurance receive emergency care at out-of-network hospitals. In such cases, out-of-network hospitals or physicians often seek the balance of the cost of services not covered by health insurers -- in some cases thousands of dollars -- directly from patients.

The state DMHC on Oct. 15 finalized regulations that deemed balance billing an unfair practice. In response, the California Medical Association and the California Hospital Association filed a lawsuit that sought to block the regulations, which the groups said could undermine current agreements between health insurers and hospitals.


The groups likely will appeal the decision issued on Tuesday (Calvan, Sacramento Bee, 12/4).

Wall Street Journal Examines Issue

The Wall Street Journal on Thursday examined the "nasty surprise" of balance billing. "It's not clear how much balance billing occurs in the U.S., but the practice appears to be widespread," according to the Journal. In response, a "growing number of state regulators" -- such as those in California, Illinois and New York -- have begun "moving to crack down on balance billing," the Journal reports.

"Physician groups say doctors have the right to refuse to sign up with insurers' networks, and regulators shouldn't bar doctors who don't participate in health plans from billing insured patients" as "insurers' payments to out-of-network health providers are often unfairly small," according to the Journal. In addition, health insurers maintain that "they shouldn't be forced to pay whatever fee out-of-network health care providers demand" and "defend how they calculate payments they make to out-of-network" providers, a process that often uses a "database of medical claims price information," the Journal reports (Wilde Mathews, Wall Street Journal, 12/4).

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