Forty-seven states ban in-network providers from billing insured patients more than their required copayment or deductible and federal law prohibits providers from billing Medicare beneficiaries for unpaid balances. Some states also ban additional charges for insured patients who seek care from out-of-network providers and emergency departments. While national statistics on the practice are unavailable, economists and patient advocates estimate that consumers pay at least $1 billion annually for medical bills that they are not legally responsible to pay.

Pennsylvania law (Title 34, Chapter 127) provides that “it shall be unlawful for any health care practitioner, or any primary health center, corporation, facility, institution or other entity that employs a health care practitioner, to balance-bill [Medicare].”  § 127.211. Balance billing prohibited. (a)  A provider may not hold an employee liable for costs related to care or services rendered in connection with a compensable injury under the act. A provider may not bill for, or otherwise attempt to recover from the employee, the difference between the provider’s charge and the amount paid by an insurer.  (b)  A provider may not bill for, or otherwise attempt to recover from the employee, charges for treatment or services determined to be unreasonable or unnecessary in accordance with the act or Subchapter C (relating to medical treatment review).

By contrast, Kentucky law applies only to certain payers, those that offer a health benefit plan that is not a managed care plan (as defined under state law) but that does provide financial incentives for a covered person to access a network. Those plans’ contracts must include a “hold-harmless agreement under which the covered person will not be balance-billed by the in-network provider, except for deductibles, co-pays, coinsurance amounts, and non-covered benefits.”

Other states extend the prohibition to private payers and out-of-network physicians.

Florida law, for example, provides that a physician or any representative of a physician, regardless of whether the doctor is under contract with the plan, may not collect or attempt to collect money from, maintain any action at law against or report to a credit agency a subscriber of an organization for payment of services for which the organization is liable, if the physician in good faith knows or should know that the organization is liable.

Idaho law (72-432 ) states that no provider shall engage in balance billing as defined in section 72-102.  Idaho Code Title 72-102, states that “balance billing” means charging, billing, or otherwise attempting to collect directly from an injured employee payment for medical services in excess of amounts allowable in compensable claims as provided by rules promulgated by the Industrial Commission.

Likewise, in Vermont, Code Title 33, § 6502 states that balance billing is prohibited A physician who agrees to treat a Medicare or general assistance beneficiary shall not balance bill the beneficiary except as hereinafter provided. (Added 1987, No. 51, § 1.)

Other States on Balance Billing

California

Prospect Medical Group Inc. v. Northridge Emergency Medical Group, No. S142209 (Cal. filed Jan. 8, 2009); The CA SC case ruling that when the HMO and ER can’t agree on what emergency care should cost, they can’t balance bill the patient. See http://www.courtinfo.ca.gov/opinions/documents/S142209.PDF

WJS article “Balance Billing Nixed by California Supreme Court”

http://blogs.wsj.com/health/2009/01/09/balance-billing-nixed-by-california-supreme-court/

Article: “California Supreme Court Rules Against Balance Billing By Hospitals, ED Physicians When HMOs Decline To Pay Some Out-of-Network Care Costs”

http://www.medicalnewstoday.com/articles/135010.php

LA Times article: “Ruling removes headache from emergency room visits”

http://www.latimes.com/news/local/valley/la-fi-emergency9-2009jan09,0,5100511.story

Article: “California Supreme Court Bans Balance Billing for ER Patients”

http://www.healthlawyers.org/Members/PracticeGroups/PPMC/emailalerts/Pages/CaliforniaSupremeCourt.aspx

New Jersey

Proposed Amendment: N.J.A.C. 11:1-5.1:

http://liberty.state.nj.us/dobi/proposed/prn08_392.pdf

New York

Office of Attorney General article: “ATTORNEY GENERAL CUOMO ANNOUNCES HISTORIC NATIONWIDE HEALTH INSURANCE REFORM; ENDS PRACTICE OF MANIPULATING RATES TO OVERCHARGE PATIENTS BY HUNDREDS OF MILLIONS OF DOLLARS”

http://www.oag.state.ny.us/media_center/2009/jan/jan13a_09.html

NY Times article: “Big Health Insurer Agrees to Update Its Fee Data”

http://www.nytimes.com/2009/01/13/health/policy/13care.html

Article: “United HealthGroup to pay $50M to settle charges of rigged rates”

http://www.healthcareitnews.com/news/united-healthgroup-pay-50m-settle-charges-rigged-rates

Article: “UnitedHealth Group, Cuomo reach deal on Ingenix”

http://www.modernhealthcare.com/article/20090114/REG/301149993

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This entry was posted by Adam V. Russo on Wednesday, February 4th, 2009 at 10:22 am and is filed under California, Florida, Idaho, Kentucky, New Jersey, New York, Pennsylvania, Vermont. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.