Published: Sunday, Dec. 14, 2008
“The root cause of balance billing is HMOs and other insurers not paying the bills. We don’t want patients to have to pay a bill that their insurers say they would pay”
The car crash was horrific: A Rocklin teenager lay crunched under the dash of a crumpled car, her neck and back fractured, her internal organs bruised and ruptured.
Melyssa Ingalsbe’s recovery has been slow and agonizing, complicated by months of frustration over $16,000 in medical bills – out of $130,000 – that her insurance company declined to pay and that doctors and a Bay Area hospital insisted she owed for life-saving surgery and the nine days she spent in intensive care.
Unable to get payment from Health Net, the medical group sent her account to a collection agency…
Adams and her daughter felt the squeeze of a practice known as “balance billing.” A benign-sounding practice, it’s now at the heart of one of the most pressing controversies in managed care.
Insurers negotiate fees with hospitals and doctors and establish health care networks. But providers who aren’t part of the network aren’t bound by those fees – and when an insurer declines to pay the full bill, physicians and hospitals try to collect the balance directly from the patient.
Earlier this month, a Sacramento Superior Court judge affirmed the authority of the state Department of Managed Health Care to deem balance billing an unfair practice. The California Medical Association, which sued to stop the regulation, says it will appeal.
The state Supreme Court is about to weigh in on the practice. It is expected to rule soon on a Southern California dispute between two medical groups that could partly answer, but hardly resolve, the question of whether balance billing is legal.
State regulators promise increased vigilance on balance billing.
“We don’t see it as a minor problem. What we see are patients at the mercy of the system,” said Cindy Ehnes, director of the state’s Department of Managed Health Care, which regulates health maintenance organizations in California.
California has about 21 million people – more than half the state’s population – enrolled in plans offered by HMOs.
Since 2006, more than 1.75 million Californians who received emergency room care were billed by doctors and hospitals for balances beyond…
