balance billing

Balance billing ban upheld

Dan Bowman — Thu, 04 Dec 2008 12:24:47 -0500

In yet another chapter in the ongoing saga of balance billing, a judge in Sacramento recently affirmed state regulations looking to protect consumers from the practice. Last month, physicians in California challenged the ban put on balance billing by the state, citing that doctor's shouldn't be punished for the stinginess of HMOs. Subsequently, Francisco J. Silva, the general counsel to the California Medical Association, wanted the California Department of Managed Health Care (DMHC) to go after HMOs, forcing them to pay more.

Still, Sacramento Superior Court Judge Michael P. Kenny, who "tentatively sided with the state" on the matter in November, upheld the department's regulations on Tuesday, even after hearing arguments from both the California Medical Association and the California Hospital Association.

Cindy Ehnes, director of the CDMHC, believes the ruling will help providers to get their money in a timely fashion, as well as protect consumers. "All along, the Governor and his Administration's goal has been to protect consumers from unfair and illegal balance billing," she said.

But don't expect the CMA to take the finding lying down; they more than likely will appeal the case.

For more on balance billing:
- check out the Sacramento Bee article

California balance billing ban challenged in court

Anne Zieger — Thu, 13 Nov 2008 10:06:24 -0500

California physicians were already up in arms about the new ban on balance billing before it even went into effect. So it's little wonder that they have wasted no time in challenging the ban in court.

Doctors in California feel they shouldn't be punished for the HMO's stinginess, and wonder why the DMHC doesn't go after the HMOs and make them pay more, rather than prohibiting doctors from balance billing to try to make ends meet.

As Francisco J. Silva, the general counsel to the California Medical Association, points out, the job of regulators is to protect Californians from HMO's tendencies to underpay. What the CMA is objecting to (and trying to fight) is how the Department of Managed Health Care (DMHC) goes about that. The DMHC, for its part, says it is confident that its regulations will withstand these challenges.

To learn more about the dispute:
- read this AMNews piece

California bans balance billing

Anne Zieger — Thu, 16 Oct 2008 09:28:34 -0400

Capping years of debate, a new law just went into effect in California banning balance billing, a landmark measure that may further shift the balance of power in the direction of health plans. Several legal challenges regarding balance billing are going before state courts soon, but in the meantime, some hospitals are panicking about how to make ends meet when insurers underpay them.

Among the key backers of the bill was the state's Department of Managed Health Care, which argued that under existing state laws, consumers were having their credit ruined because they didn't pay the hospital's bill, or were paying out of pocket because they didn't know that they weren't responsible for that payment.

Many doctors and hospitals, however, are claiming that this law is unfair. They claim that the Department of Managed Health Care should be acting more quickly against the insurance companies when they underpay or make late payments, instead of going after the doctors themselves, who are just trying to get the money they need to keep in business.

To learn more about this law and the court battles:
- read this L.A. Times piece

CA providers, officials fight over balance billing

Anne Zieger — Mon, 11 Aug 2008 10:43:50 -0400

The battle is on in California over the issue of when it's legal to balance-bill patients, with providers contending that they need to issue such bills when health plans underpay. The dispute comes because in that state, the law is apparently unclear on a key issue--whether providers who don't contract with a health plan can balance-bill patients who see them as out-of-network providers.

At present, the California Department of Managed Health Care is suing Prime Healthcare Services in an effort to stop the hospital network from billing patients for out-of-network emergency care fees. The DMHC contends that Prime illegally billed up to 6,000 Kaiser Permanente members for outstanding balances, as well as members of other health plans. (It doesn't help matters any, politically, that Prime has made a routine practice of dropping managed care contracts when it acquires a hospital, seemingly in an effort to get higher out-of-network reimbursement rates.) The DMHC argues that state law bans balance billing for emergency care because doctors and hospitals have an implied contract to treat patients in emergencies--as required by EMTALA--which gives insurers the obligation to pay for services.

Providers don't care for the DMHC's reasoning, according to AMA newspaper American Medical News. They say that under this interpretation of the law, health plans can unilaterally decide what they're going to pay, and are likely to pay unfair rates for emergency services. They note that balance billing for emergency services was found legal under a 2006 state appeals court ruling, which held that "contracting providers" who can't balance bill are only those with an actual contract.

Meanwhile, the DMHC continues to press forward with regs banning all balance billing, as mandated by Gov. Arnold Schwarzenegger (R) in 2006.

To learn more about this dispute:
- read this AMNews piece

Related Articles:
CA sues Prime Healthcare for balance-billing insured patients
CA law would ban balance billing for ED services
Schwarzenegger orders end to balance billing

CA sues Prime Healthcare for balance-billing insured patients

Anne Zieger — Wed, 02 Jul 2008 12:20:59 -0400

California regulators have filed suit to stop growing hospital chain Prime Healthcare Services from billing commercially-insured patients for fees that insurance companies don't pay. The practice, known as balance billing, is explicitly forbidden in some states, but California law is vague on this topic, according to observers. However, Prime's practices are so extreme in this regard that they must be stopped, according to the state's Department of Managed Health Care (DMHC).

Prime, one of the fastest-growing hospital chains in California, has acquired a dozen southern California hospitals in recent years. Along the way, it has acquired a controversial reputation, as it often cancels the majority of private insurance contracts these hospitals had in place. Such cancellations allow the hospitals to bill insurers for out-of-network services, allowing Prime to charge higher fees.

Aware of Prime's strategy, and upset at what they see as inflated bills, some insurers have begun sending Prime only partial payments for members treated at its hospitals. Prime, in turn, has been billing patients for the remainder of its fees, sometimes to the tune of as much as $50,000, which has generated a firestorm of protest among patients, insurers and state officials.

In its lawsuit, the DMHC is asking the court to forbid Prime to bill insured patients for bills owed by insurers. This follows previous legal action by Kaiser Permanente, which obtained a temporary restraining order barring the chain from collecting from its members or reporting the bills to credit agencies until the case is resolved.

To learn more about the case:
- read this Los Angeles Times article

Related Articles:
Prime Healthcare picks up three Tenet facilities
California hospital operator boots HMOs
Upstart CA hospital chain buys another facility
State stops acquisition by growing CA hospital chain