RICHMOND — Surprise bills — sometimes for thousands of dollars — for medical care that Virginians expected insurance to cover are on the rise, a General Assembly health care panel heard Monday.
In response, the chair of the legislature’s Health Insurance Reform Commission, Del. Kathy Byron, R-Bedford, said the legislature will act to enhance consumer protection.
The surprise bills arise in many ways. For example, patients can go to doctors in their insurers’ networks, who then order a test from a lab that has no agreement with the insurance.
One of Anthem Blue Cross Blue Shield’s Peninsula members ran into that, with a $3,687 bill for urinalysis tests over three months “that I can get done at Rite Aid for $50,” Anthem Program Director for Provider Solutions Julie McGarrh told the panel. One of those tests was billed at $1,229, she said.
“There’s no excuse for these kinds of charges for something somebody else is making money with at $50. Basically, it’s fraud,” snapped state Sen. Frank Wagner, R-Virginia Beach.
Another so-called “balance billing” surprise commonly comes when patients go to the emergency room at a hospital in their insurers’ network and get a separate bill from an anesthesiologist or pathologist. The bills come because those doctors are not in the network and haven’t agreed with the insurer on the fee for their services, said Don Beatty, deputy commissioner for policy at the state Bureau of Insurance.
While state law prohibits in-network doctors or hospitals for separately billing patients for more than the rate they negotiated with an insurer, that ban doesn’t apply for providers who aren’t in a network.
State law also says insurers must pay for emergency care at out-of-network hospitals on the same terms that they pay for in-network care — but also allow an out-of-network hospital to bill patients directly for any difference over its charges.
Balance billing is also a costly problem with air ambulance services, Beatty said.
Another issue is when people go to an out-of-network ER and then are told they need to stay in the hospital for follow-up care, said Jill Hanken, director of the Virginia Poverty Law Center’s healthy communities program.
She said the legislature should enact laws holding patients harmless in such emergency situations and leave it to insurers and providers to sort out the differences.
State Sen. Ryan McDougle, R-Hanover County, said her proposals were probably a reach too far.
But, he added, “I want to say that the clock is ticking … we’re not going to go with remaining with what we’re doing.”
One problem is the complex relationships between hospitals, doctors and other providers of health care, often invisible to patients. Often, those relationships are formed because they’re a way of making more money, said Doug Gray, executive director of the Virginia Association of Health Plans.
“If there are incentives to profit from balance billing, it will continue,” he said.
Hospitals try to tell people if care isn’t covered on an in-network basis so that separate charges would be billed, said R. Brent Rawlings, general counsel for the Virginia Hospital and Health Care Association.
But Trisha Anest, an ER physician at Mary Immaculate Hospital, said she hadn’t had time to ask about insurance coverage for the 26 people, ranging in age from 11 days to 97 years, she saw during her shift immediately before the panel’s meeting.
ER services run at a loss, and maintaining the state’s safety net of emergency rooms that take all comers is essential, she said.
McDougle said insurers, health care providers and patient advocates needed to agree on a way to tackle the problem, “or else we will, and I promise you that’s going to make somebody unhappy.”
Byron said later that she thought better disclosure would help, and added that the legislature will also have to think about the responsibilities of hospitals and other providers that operate in hospitals when one is in a network and the other is not.
But the issue is complicated, she said. The General Assembly needs to be sure that the enhanced consumer protections she wants to see don’t end up making insurance even more expensive, Byron added.