The heathcare reforms in the 2010 Patient Protection and Affordable Care Act remain a work in progress, with some of the law's mandates causing new problems or exacerbating older flaws. One is inaccurate lists of the healthcare providers in insurers' networks; another is surprise bills by out-of-network providers. California lawmakers have offered proposals to solve these problems, and the Legislature should pass them.
Insurers have been exploring ways to hold down rates by signing up smaller networks of doctors and hospitals, and the 2010 law accelerated that trend. Such “narrow networks” can be a good thing for consumers, provided that the doctors on the list can meet the demand for care and have offices throughout the service area.
Still, people want to know before they sign up for a narrow network plan whether they'll be able to keep the doctors they like, or how far they'd have to travel to see someone willing to take new patients. And in too many cases, they've enrolled only to be turned away by doctors who were purportedly in their plan's network, either because the list was inaccurate or the doctors didn't understand their contract with the insurer.
SB 137 by state Sen. Ed Hernandez (D-West Covina) would require insurers to publish provider lists online and update them weekly, including information about office locations, specialties, languages spoken and willingness to accept new patients. To avoid penalties, the lists would have to be at least 97% accurate and be available to anyone who's interested.
In an era of electronic payments and digital health records, it's hard to believe that insurers can't keep track of who's in their networks, what services they provide and where their offices are. Insurers argue that doctors should bear some of the responsibility for the records' accuracy, and they're right; the bill's supporters should explore ways to make sure providers know and abide by what their contracts require.
One reason it's crucial to know who's in a network is that the cost of seeing an out-of-network provider for nonemergency care can be ruinously high. Insurance plans cover a smaller percentage of out-of-network bills, if they cover them at all, and unlike in-network providers, out-of-network doctors don't agree to discounted fees.
Even when patients arrange for care from in-network hospitals and doctors, however, they can still be hit with huge bills from out-of-network specialists and assistants they had no idea would be involved in their care. In the most egregious cases, an in-network surgeon will bring in an affiliated specialist or laboratory not in the patient's network in order to multiply the fees.
AB 533 by Assemblyman Rob Bonta (D-Alameda) would protect patients who go to in-network hospitals from being billed at out-of-network rates for any service received there. The only exception would be for patients who agree at least a day in advance to receive and pay for out-of-network services. In effect, the bill would hold patients harmless while insurers and providers squabble over the fees for out-of-network services.
The measure has drawn the ire of physician groups, which argue that protecting patients against out-of-network charges would encourage insurers to leave gaps in their networks — a problem that legislators addressed in the last session by requiring regulators to check the adequacy of most plans' networks every year. More legitimately, the groups want a better way to resolve fee disputes between insurers and physicians. That's a worthy goal, but it shouldn't stop lawmakers from protecting the patients who are caught in the middle.
The opposition to both measures reflects the potentially difficult adjustments insurers and providers would be forced to make in their operations. Those adjustments, however, are overdue. With the Affordable Care Act requiring all adult Americans to buy coverage, insurers simply have to deliver accurate provider lists. And providers shouldn't be able to undermine that insurance by seeking out-of-network rates from patients who stay within their networks for care.