Surprise medical bills targeted in Georgia Senate bill

A patient with standard private health insurance can go to the emergency room, get treated, get home — and then get sky-high bills from individual doctors or services that weren’t covered.

It’s perfectly legal.

Legislators are trying a fix this year, similar to what they already tried last year in vain. But this year is different, they say. Those who aim to force insurance companies to cover some of these bills say the public has seen such bad news from insurance companies in the past year — such as skyrocketing premiums and Blue Cross Blue Shield’s decision not to pay for contested emergency room visits — that opinions are changing.

Insurance companies counter: Think again. They insist that the solution on the table, Senate Bill 359, would not be fair.

SB 359 cleared the Senate Health and Human Services Committee on Thursday. If the Senate approves it Wednesday, it will then go to the House for consideration.

The bill would force insurance companies to cover services that their customers receive when they go to the emergency room. The key is that, in the absence of a contracted price negotiated between the out-of-network provider and the insurance company, the law would make companies accept rates that come from an independent database.

The database, which apparently is the FAIR Health database set up by the state of New York as part of an insurance investigation settlement there, says it contains rates paid by insurance claims. It says it tracks more than 1 billion new payment reports every year to keep the data current.

Insurers offer sharp criticisms for the database, saying it’s actually just a record of what doctors choose to charge.

“If insurers and their members, Georgia’s self-employed and small businesses, are forced to pay 300 to 1,000 percent more for services, then we move from surprise bills to surprise premiums,” said Graham Thompson, a lobbyist for Georgia insurers.

“The money has to come from someone to cover costs,” he said. “Allowing one party to set prices raises real concerns about affordability.”

Doctors backing the bill, such as Dr. Chip Pettigrew, who advocates for emergency physicians, say the insurers are using “fictitious” data to attack the database, and they’re the ones raking in the money.

“I think the writing’s on the wall,” said Dr. Matthew Keadey, also an emergency physician. “Everyone needs to do something.”

It’s all about the increasingly tortured negotiations between medical providers and medical insurers. Insurers’ networks of doctors whom their patients can see for the contracted price are getting narrower and narrower every year. Doctors say insurance companies are now so few and so powerful that the contracts they offer leave doctors with little choice. Insurers say doctors just want to charge what they want.

In the middle are the patients, the one member of the fight with no deep-pocketed lobbyists at the Capitol.

So far, the fight has ended with patients getting socked with the bills with no solution in sight. A similar bill last year passed the same committee and the state Senate, but it died in the House.

One patient advocacy group, Georgians for a Healthy Future, has backed SB 359.

For non-emergency services, the bill doesn’t necessarily offer coverage, but it aims to offer a bit more transparency — if the patient is able to track down information.

It says hospitals and doctor-owned surgery centers would be obligated to post online the names of doctors the facility uses that may charge additional fees, or they must provide the names to the patient 48 hours in advance. It would then be up to the patient to find out from their main doctor who else will participate in their procedure, such as anesthesiologists and radiologists — and then to contact those doctors to ask if they’re in the patient’s insurance network.

As cumbersome as that seems, advocates say it would be an improvement over the lack of updated, accurate information currently available to patients on insurance networks.

If the procedure’s staffing changes unexpectedly, the center or hospital would be off the hook. Unexpected events resulting in surprise bills to patients over $1,000 could go to mediation.

Last year the House had its own bill, House Bill 71, that would have attacked the problem from the other direction, forcing doctors into the network that the hospital chose for them and hoping they could negotiate a favorable price from the insurers. That bill cleared a House committee but did not succeed in a floor vote.

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