By Holly Hayes
As noted in a previous post (available here) Texas House Bill 2256, signed into law on June 19, 2009, provides a procedure for mediation of out-of-network health benefit claim disputes. The law gives patients 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, and neonatologists. ‘Balance billing’ occurs when a physician bills a patient for the difference between what the physician charges for a service and what an insurer pays the physician for that service. When a physician is not in-network for an insurer, there is no contracted payment rate that the physician has agreed to accept from the insurer so the insurer can pay what is deemed appropriate and the patient is billed for the difference.
At the federal level, H.R. 3962, the “Affordable Health Care for America Act” is currently being considered in Congress. The bill defines ‘cost sharing’ (see bottom of page 9) and specifically excludes “premiums, balance billing amounts for non-network providers, or spending for non-covered services.” Although the bill says that out-of-pocket payments are capped for an individual at $5,000 or $10,000 for a family, out-of-network balance billing amounts are not included in those caps. Find out more at the The Wall Street Journal Health Blog(here).
Look for an analysis of how other states are approaching ‘balance billing’ in a future post.
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 University and a Masters in Health Administration from Duke University. She can be reached at: email@example.com.