Opinion - Editorials
Comments (0) | | Print

Editorial: Patients get out of the crossfire

Published: Monday, Aug. 11, 2008 - 12:00 am | Page 18A
Last Modified: Monday, Aug. 11, 2008 - 12:28 pm

Too often, people who end up in an emergency room also end up being charged for services and paying bills they don't owe – bills that their health insurers are legally obligated to pay.

It happens this way: In emergency situations, patients sometimes get their care from doctors in emergency rooms outside their insurance networks. Some of these doctors believe that the payments they receive from insurers are too low, so they send bills to patients for the difference – a practice called "balance billing."

Many times, consumers don't realize that these bills should not be their responsibility, and they pay them. And if they don't pay, they get collection agencies hounding them and credit agencies downgrading their credit rating.

Here's an example. In April, Prime Healthcare Services, a hospital chain in Southern California, sent collection notices to nearly 6,000 people with Kaiser insurance who had received emergency care at its hospitals. The California Association of Health Plans estimates that more than 1.75 million insured Californians who visited emergency rooms in the past two years were billed after paying their co-payments and deductibles – an average of $300.

Well, as Gov. Arnold Schwarzenegger has said, the patient shouldn't be caught in the middle of what is really a pay dispute between doctor and insurer. So the governor and the California Department of Managed Health Care finally have put an end to it.

It has taken two long years, but it's done. In July 2006, Schwarzenegger issued an executive order, then attempted over the last two years to get a compromise between feuding insurers and emergency room doctors on regulations – to no avail. On Friday, the department simply issued regulations outlawing the practice. These take effect Oct. 15, after a September hearing and publication by the secretary of state.

This is a major health care victory for Californians. Patients who face a medical emergency and end up in an emergency room no longer can be billed for services that are covered by their health insurance.

Doctors complain that they are forced into the practice because insurers deliberately follow an underpayment strategy. But as the department has pointed out, existing law doesn't allow insurers to underpay out-of-network doctors or to unilaterally set reimbursement rates to doctors.

The law requires insurers to pay out-of-network doctors the "reasonable and customary" value of their services. If a doctor believes the insurer is underpaying, the law requires health plans to provide "a fast, fair and cost-effective dispute resolution mechanism under which providers may submit disputes to the plan."

If that fails, the doctor then may go to the state Department of Managed Health Care's independent dispute resolution process. The department does a review to determine whether claims should have been paid or whether interest is due. It also looks for evidence of unfair payment patterns by the insurer that might merit further action.

The new regulation recognizes that the patient doesn't belong in the middle of this. Billing patients who have already paid their health insurance premiums, co-payments and deductibles should be no substitute for going after insurers to pay bills they are legally obligated to pay.


About Comments

Reader comments on Sacbee.com are the opinions of the writer, not The Sacramento Bee. If you see an objectionable comment, click the "report abuse" button below it. We will delete comments containing inappropriate links, obscenities, hate speech, and personal attacks. Flagrant or repeat violators will be banned. See more about comments here.

What You Should Know About Comments on Sacbee.com

Sacbee.com is happy to provide a forum for reader interaction, discussion, feedback and reaction to our stories. However, we reserve the right to delete inappropriate comments or ban users who can't play nice. (See our full terms of service here.)

Here are some rules of the road:

• Keep your comments civil. Don't insult one another or the subjects of our articles. If you think a comment violates our guidelines click the "report abuse" button to notify the moderators. Responding to the comment will only encourage bad behavior.

• Don't use profanities, vulgarities or hate speech. This is a general interest news site. Sometimes, there are children present. Don't say anything in a way you wouldn't want your own child to hear.

• Do not attack other users; focus your comments on issues, not individuals.

• Stay on topic. Only post comments relevant to the article at hand. If you want to discuss an issue with a specific user, click on his profile name and send him a direct message.

• Do not copy and paste outside material into the comment box.

• Don't repeat the same comment over and over. We heard you the first time.

• Do not use the commenting system for advertising. That's spam and it isn't allowed.

• Don't use all capital letters. That's akin to yelling and not appreciated by the audience.

You should also know that The Sacramento Bee does not screen comments before they are posted. You are more likely to see inappropriate comments before our staff does, so we ask that you click the "report abuse" button to submit those comments for moderator review. You also may notify us via email at feedback@sacbee.com. Note the headline on which the comment is made and tell us the profile name of the user who made the comment. Remember, comment moderation is subjective. You may find some material objectionable that we won't and vice versa.

If you submit a comment, the user name of your account will appear along with it. Users cannot remove their own comments once they have submitted them, but you may ask our staff to retract one of your comments by sending an email to feedback@sacbee.com. Again, make sure you note the headline on which the comment is made and tell us your profile name.


Sacramento Bee Job listing powered by Careerbuilder.com

Quick Job Search
Buy
Used Cars
Dealer and private-party ads
Make:

Model:

Price Range:
to
Search within:
miles of ZIP

Advanced Search | 1982 & Older