Insurance Commissioner Applauds Introduction of Legislation to Protect Consumers From Surprise Balance Bills

HARRISBURG, Pa., June 20 -- The Pennsylvania Insurance Department issued the following news release:

Insurance Commissioner Teresa Miller today commended House Health and Insurance Committee Chairs Matt Baker and Tina Pickett for introducing legislation to protect health care consumers from surprise balance bills.

"Surprise balance bills happen when consumers make a good faith effort to use providers and facilities in their insurance network, but receive a service from an out-of-network provider or facility during treatment, and then get a balance bill for this service," Commissioner Miller said. "As part of Governor Wolf's commitment to consumer protection, I have been working with legislators on a proposal to shield consumers from the often large and unexpected bills since I held a public hearing on the topic in October, 2015, and am gratified to have the support of key committee chairs on this important issue."

The legislation, HB 1553, which has 31 sponsors including Health and Insurance Committee minority chairs Tony DeLuca-D/Allegheny County, and Florindo Fabrizio-D/Erie County, would protect consumers from surprise balance bills when the consumer makes a good faith effort to use in-network providers and facilities, but during the course of medical care, receives a services from an out-of-network provider or facility. The legislation would require insurers and providers or facilities to work out payment for out-of-network services, with the consumer being responsible only for payments equal to any cost-sharing they have for in-network services.

"During testimony at the public hearing and in correspondence over the past two years, I heard from a patient who underwent emergency heart surgery from an out-of-network surgeon, from parents whose baby received needed neo-natal care from the only neonatologist available, who was out-of-network, and from women whose mammograms were read at out-of-network facilities, all of whom then received surprise balance bills," Commissioner Miller said. "These stories make it clear this practice must stop."

If the insurer and provider or facility cannot reach agreement on payment for out-of-network services, the matter would be submitted to arbitration, with each side submitting its last best offer. In what is known as "baseball arbitration", the arbitrator would then choose one of the offers, and this decision would be binding on both parties. The consumer would not be involved in this process.

Commissioner Miller emphasized this legislation would apply to emergency room care. She noted in emergency situations consumers often have no choice as to which provider or facility delivers care, and thus have no say in whether the care is in-network.

Similar legislation, SB 678, has been introduced in the Senate by Senator Judy Schwank-D/Berks County, Insurance Committee Chair Don White, and Minority Leader Jay Costa, and seven other co-sponsors.

"It's very important to get the patient out of this equation. Somebody who has done everything reasonable to make sure they are within their network should not face hidden, and often expensive, bills because of struggles between providers and insurers. Too often that's what is happening now," Sen. Schwank said.

"When patients receive medical care, they and their families should be focusing on getting better, and not worrying about whether a big medical bill will be arriving in the next day's mail," Commissioner Miller said. "This legislation will go a long way toward making that happen in Pennsylvania."