ATLANTA — Lawmakers, hospitals and insurers agree: it’s time to remove the patient as the middle man between navigating their insurance and hospital services.
But no one can agree how.
Lawmakers are struggling to please both hospitals and insurers as they try to address surprise billing.
Legislators have attempted to curb patients receiving unexpected post-care bills from doctors and staff that are independent contractors of a hospital, but not covered by the patient’s insurance, but in the process, have to avoid telling hospitals or insurers how to do their jobs.
Action has stalled at a federal level, making it a priority in both chambers this session. But stakeholders on both sides are saying they aren’t accountable for the coverage loophole.
Several bills have been introduced but none seem to put a direct end to the practice of surprise billing.
A House bill that pushes transparency over a fix was heard Monday and moved forward by the House Special Committee on Access to Quality Health Care — with one vote against.
Rep. Mark Newton, R-Augusta, chairman of the special committee, presented his plan to lawmakers called the Surprise Bill Transparency Act.
The legislation would require insurance agencies to post online which hospitals in their network have specialty services performed by doctors who are also in their network for the four most common specialties: anesthesiologists, pathologists, radiologists and emergency medicine physicians.
But hospitals worried the rating system of four “green checks” gives a negative connotation to hospitals that wouldn’t have the full staff coverage.
Kathy Butler Polvino testified on behalf of the Georgia Alliance of Community Hospitals that it is not the hospital’s fault if a specialty provider is out of network.
“Our concern is that this bill and the rating system could cause confusion where hospitals are being forced into the middle,” she said.
An original form of the bill included red “X’s” if a specialty provider was not covered by insurance, but it was changed to an absence of a check instead, which hospital advocates said they appreciated.
However, the rating system is not a guarantee. If an insurance company incorrectly marks a hospital’s doctor as in network, a patent is still at the risk of receiving a surprise bill.
Newton said they’re doing as much as they can without telling insurers or hospitals what to do.
“I don’t want to tell insurance what they have to pay, I don’t want to tell physician groups what they have to take and a percentage of Medicare and arbitrate all that,” Newton told the committee. “At least, that’s not my particular goal in this bill. It is the goal in this bill to just shine a bright spotlight on it first.”
Newton said he hopes the rating system will put pressure on insurance companies to compete in providing the best scope of in-network coverage of hospital specialty providers.
Rep. Spencer Frye, D-Athens, was the lone vote against the bill moving forward.
“I will be voting against it only because I don’t think that it does enough,” he said. “If we’re going to start tackling these issues that we really need to focus on reining in these out-of-control insurance companies.”
A spokeswoman for the Georgia Association of Health Plans said the group is closely following the surprise billing issue in the legislature.
“Georgia Association of Health Plan members are working with the House, Senate and Governor’s Office as well as the other stakeholders involved to find a compromise that takes patients out of the middle and keeps health-care costs low,” the association said in an email statement to CNHI.
Surprise billing is also at the top of the Senate Majority’s 2020 priorities, which Senate leaders said should have been solved years ago.
Earlier in the session, lawmakers introduced the bill they hope finally makes it to the governor’s desk. The Surprise Billing Consumer Protection Act would establish consumer protections against surprise bills from medical services.
Sen. Ben Watson, chair of the Health and Human Services Committee, said drafting a good bill means finding a balance between both holding insurance companies as well as hospitals accountable for billing patients inaccurately.
The legislation would mandate billing off of a price list of what government-regulated insurance companies have predetermined in their contracts for emergency and non-emergency services. The State Department of Insurance would be required to create a health claims database.
The idea is to circumvent patients receiving bills for doctors and staff that are independent contractors of a hospital, but not covered by the patient’s insurance. Additional provisions for conflict resolution between parties are established.
Watson said surprise billing is one issue where state lawmakers hoped the federal level would intervene — but with no luck on federal legislation, Georgia lawmakers are left holding the bag.
Watson said in the past few weeks the Governor’s Office staff has even weighed in. But ultimately there will be aspects that both hospitals and insurance companies will disapprove.
“I think we have a good compromise that is going to be neither side is happy, but I think that will have a good piece of legislation,” he said.