Pa. insurance regulator eyes an end to 'surprise' medical bills

Ben Schmitt
| Tuesday, Jan. 19, 2016, 1:39 p.m.

Pennsylvania's insurance commissioner wants to remove the surprise factor from bills for out-of-network medical care.

On Tuesday, Commissioner Teresa Miller unveiled a proposal aimed at easing financial pain for patients adversely impacted by so-called surprise balance bills. She's asking the public to offer feedback online to the proposal that she hopes eventually will lead to legislation.

Surprise balance bills occur when a patient is charged for treatment that is not covered by the patient's insurance company. A common example of balance billing is a scenario in which a patient receives treatment from a doctor outside the patient's network. Sometimes hospitals contract with doctors, rather than employing them, and patients are surprised to receive higher charges for out-of-network care. That can happen when hospitals contract anesthesiologists or emergency room doctors.

“At a public hearing in October, I heard from consumers who, despite their best efforts to use providers in their health insurance network, still received out-of-network bills that were in the hundreds — and in some cases thousands — of dollars,” Miller said in a statement. “My department has taken the information gathered at that hearing and is now offering for comment the proposed solution being announced today.”

Under her proposal, patients would be responsible only for in-network service costs. For example, a $50 copay for in-network care would remain $50 for the same service handled out-of-network. If the doctor and insurer disagree on payment, the matter would go to arbitration.

“When an individual is faced with a major medical issue, that person needs to concentrate on getting well, and not worry about whether an unexpected medical bill is coming in tomorrow's mail,” Miller said.

Highmark Inc. spokesman Aaron Billger said the insurer looks forward to working with state leaders to address consumer protections.

“While we encourage our members to utilize in-network providers, we recognize the burden of receiving unexpected out-of-network charges from providers,” he said. “We place our members at the center of all we do, and many of our contracts offer protections to patients.”

Janice Nathan of Squirrel Hill got caught up in a balance bill dispute last year after being charged $329 for an out-of-network stress test. She underwent the test at UPMC Shadyside, an in-network facility under her plan, but learned after receiving a bill that the physician performing her procedure was an out-of-network contractor.

She appealed to UPMC and then the state and eventually prevailed. However, she acknowledged that many patients wouldn't think to do so.

“I think this new idea is wonderful,” she said of Miller's proposal. “It's going to protect a lot of people who won't have to waste the time and energy that I did. My bill was small compared to some of these others.”

The open comment period, which ends Feb. 29, “allows the department to get input from various stakeholders, including insurers, hospitals, and health care providers,” Miller said.

UPMC Health Plan officials said they hope to help patients avoid billing surprises.

“We are committed to making sure our insurance plan members have all the information they need to fully understand their coverage, including information about any costs for which they may be directly responsible,” said spokeswoman Gina Pferdehirt. “UPMC Health Plan is reviewing the commissioner's proposal and looks forward to working together to best serve health care consumers.”

Ben Schmitt is a Tribune-Review staff writer. Reach him at 412-320-7991.

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