Balance Billing

How can practices shield their patients from "surprise" bills and insurance coverage gaps?Balancing Billing

Last spring, I had the pleasure of speaking at the Texas Radiological Society annual meeting, where I learned first-hand the struggles some of our states have had in regard to the issues of "balance billing," also referred to as "surprise billing."

In the ensuing months, I have participated in an increasing number of conversations with other professional organizations to try and achieve greater influence over this vexing issue.

Patients are sometimes surprised to receive large bills for health care services they received out of network, often unexpectedly as a result of emergency services. The potential for such surprise bills has increased as health insurance plans have created narrower networks as a means of imposing tighter control over costs and associated premiums. While some insurance plans may hold members harmless for some out-of-network care provisions, federal law and most state laws do not protect patients from the potentially large liability that they may face with medical services received out of network.

While a variety of scenarios may result in a "coverage gap" and surprise bills for the balance of billed services beyond what the insurance company will pay, the most compelling circumstance relates to emergency services. Even if the patient goes to an in-network hospital, there is no guarantee that all practitioners who provide care to the patient have active contracts with the patient's insurance company. Although most patients would assume that the in-network hospital is staffed completely with in-network physicians and other allied health professionals, the move to narrow networks has created circumstances in which that is not always the case. For example, in 2014, among the three largest insurers in Texas, no in-network emergency department physician were present in at least one in five in-network hospitals.

Hospital-based physicians, including radiologists, are often swept up in this problem by providing services to patients who see an in-network specialist in an in-network hospital but do not have an active contract with the patient's insurance company. The insurance company may choose to pay the radiologist much less than he would normally receive from active contracts, or pay nothing at all. The radiologist may then choose to issue a bill for the balance between typical charges and the dollars received from the insurance company, if any. In this scenario, the radiologist issues a balance bill, the patient receives as surprise bill, and the insurance company is held harmless for this coverage gap.

Several states, such as California, Colorado, Connecticut, Florida, Maryland, New York, and Texas have tried to address this issue with various pieces of legislation. Some have passed legislation to hold patients harmless or prohibit providers from balance billing in emergency or other situations, while others require a state mediation or dispute resolution process.

While some insurance plans may hold members harmless for some out-of-network care provisions, federal law and most state laws do not protect patients from the potentially large liability that they may face with medical services received out of network.

As hospital-based physicians often bear the brunt of this problem, the American College of Radiology has had several discussions with the American College of Emergency Physicians, the American Society of Anesthesiologists, and the College of American Pathologists. Discussions are underway to develop unified consensus principles and propose solutions for this problem. While discussions with our colleagues and other hospital-based disciplines are still underway, the ACR has proposed that state-level legislation designed to address out-of-network reimbursement should embody certain principles. (Note: State-specific laws/issues might mandate some considerations; states should take steps to assess what policies would work best in their given political environment. Consultation with knowledgeable counsel and professional advisors is highly recommended.)

Insurers must meet appropriate network adequacy standards that include adequate patient access to specialty care and access to in-network, hospital-based physician specialties. State regulators should uphold such standards in approving health insurance company plans. At a minimum, benefit standards for insurance plans must be developed through legislation that mandates insurance companies create plans that include a defined, transparent, enforceable, and acceptable minimum benefit standard. If the patient's insurance plan does not provide sufficient specialty representation — an in-network physician deemed capable of providing a service covered by the minimum benefit standard — patients should be permitted to pursue treatment for those covered services via out-of-network physicians. In these circumstances, patients should be protected from excessive out-of-network billing, except for their coinsurance and deductible amounts, with the insurance companies reimbursing providers based on a legislated process.

When radiologists provide services to patients out of network, they should be offered the option of using an independent database of charges or an alternative dispute resolution method. State legislation should ensure these options to provide fair reimbursement for out-of-network imaging and image-guided services. Although various methods for determining a fair market value for out-of-network medical services exist, the details are beyond the scope of this column. However, with respect to alternative dispute resolution, experience in Texas suggests that this is an important method for adjudicating differences between providers and insurance companies when out-of-network imaging services occur.

Like beauty, the implications of balance billing are in the eye of the beholder. Radiologists rightly need to exercise their right to issue a bill for the difference between that which insurance pays, if any, for out-of-network services. Patients are shocked and dismayed when they receive a bill for professional services for care provided at an in-network facility. Insurance companies feel the need to restrict their network to providers who are willing to accept lower rates or comply with restrictive plan provisions. Regardless, referring to this problem as "surprise/balance" billing detracts from the primary problem that results from gaps in insurance coverage associated with narrow networks. It is critical that we keep the primary problem in sight as state chapters address this issue at the local level. As always, the ACR remains ready and able to help support state chapters in their legislative agendas.


BrinkBy James A. Brink, MD, FACR, Chair

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