2009 Developments in Mediation: Mediation Option for ‘Balance Billing’ in Health Care


by Holly Hayes

In June, we discussed the passage of Texas House Bill 2256, which provides a procedure for mediation of out-of-network health benefit claim disputes. Patients in Texas now have the option to mediate when they are ‘balance-billed’ by their insurance company for services provided by out-of-network facility-based physicians like radiologists, pathologists, neonatologists, and emergency room physicians. (post available here)

In October, the Dallas Morning News reported on the practice of ‘balance billing.’ The article cited an example of a patient who went to an emergency room in Denton to receive treatment. The hospital was in his insurer’s network, but the emergency room physician was not. The patient was billed for the balance not paid by his insurer. (read more here)

In November H.R. 3962, the “Affordable Health Care for America Act,” was introduced in the U.S. House. (bill status is here) In the definition of “cost sharing,” the bill specifically excludes “balance billing amounts for non-network providers” in out-of-pocket payments which are capped for an individual at $5,000 or $10,000 for a family. Balance billed amounts would not be included in the out-of-pocket caps. (read more here)

According to the Wall Street Journal, while other states have addressed aspects of ‘balance billing,’ no other states appear to have included an option for patients to request mediation for resolution of ‘balance billing’ amounts. Some states have banned ‘balance billing’ of the patient altogether. In January, the California Supreme Court ruled that emergency-room patients can no longer be billed by hospitals and doctors for treatment that is not fully paid for by their health plans and that billing disputes must be resolved solely between providers and health plans. The California Department of Managed Health Care said that Connecticut, Alabama, and Pennsylvania have also banned ‘balance billing.’ (read more here)

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Holly Hayes is a mediator at Karl Bayer, Dispute Resolution Expert where she focuses on mediation of health care disputes. Holly holds a B.A. from Southern Methodist Universityand a Masters in Health Administration from Duke University. She can be reached at: holly@karlbayer.com.

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