Virginia Regulators Propose Rules For Uncovered Medical Bills, But Not Surprise ER Bills
State regulators want to require health care providers to warn patients that they may get hit with out-of-network charges, a move that comes on the heels of several failed bills in this year's General Assembly aimed at protecting Virginians with health insurance from having to pay unexpected medical bills.
But the proposed rules don't address surprise bills arising from emergencies, a key concern among lawmakers and advocates who've pushed for changes.
More than half of Americans have received a medical bill for something they believed would be covered by insurance, according to a 2018 survey by the National Opinion Research Center at the University of Chicago, a nonpartisan policy research institution.
In many cases, the patient is caught in the middle of a dispute between health care providers and insurance companies. When a patient is unknowingly treated by a health care professional who does not have an in-network negotiated rate with the patient's insurance company ' even if the hospital where the patient received the care is in-network ' the patient will receive a bill for the out-of-network service. The bills can range from hundreds to hundreds of thousands of dollars.
The State Corporation Commission, which regulates insurance companies in Virginia, last week announced proposed regulations that would require health care providers that contract with managed care health plans to give advance notice to patients informing them that they could be treated and billed by an out-of-network provider. The patient could then decline to receive out-of-network services or agree to pay the full cost not covered by insurance.
The proposal comes as federal legislators are trying to find a bipartisan solution to surprise medical bills, which President Donald Trump has named as a legislative priority.
Doug Gray, executive director of the Virginia Association of Health Plans, which represents insurance companies in the state, said that the SCC's proposed regulation is a good first step in protecting health care consumers from getting surprise bills.
"What's good about this proposal is that it requires that the consumer be offered the opportunity to only be treated by in-network providers," Gray said.
But the regulations stop short of protecting patients who receive out-of-network emergency care, an issue that has received attention because patients experiencing an emergency often can't decide where to be treated.
Adam Brown, an emergency physician and executive with Sentara Northern Virginia Medical Center, said he has seen his patients struggle with unexpected costs after a visit to the emergency room.
Another problem that has arisen from the fear of uncovered medical costs is that some people are making medical decisions based on finances rather than medical necessity, Brown said.
He recalled one recent scenario he witnessed where a mother's daughter was ill and needed to be transferred to a pediatric unit. The mother wanted to drive her daughter there rather than risk a crippling ambulance bill.
"She was so worried about the cost of ambulance, she wanted to tackle NoVa traffic into D.C.," Brown said.
Brown said he believes the SCC's proposed regulations don't do enough to protect patients. He supports rules on the state and federal levels that would require surprise bills for emergency services to go into an arbitration process between the provider and the insurance company ' taking the patient out of the equation.
The Virginia Hospital and Healthcare Association, which represents 110 hospitals, supported the state legislation that would have required insurance companies to pay for all emergency services, including those out-of-network, at rates determined by the average cost of similar services in the region. The bill passed the Senate unanimously with support from several health care provider groups, but ultimately died in the House of Delegates money committee. It was instead assigned to a work group that will report to the committee later this year.
The insurance providers opposed the measure, saying it would lessen incentives for providers to negotiate in-network rates and potentially drive up premium costs, according to Gray.
Julian Walker, vice president of communications for VHHA, said that many hospitals in the state already make an effort to be transparent with consumers about costs for elective care, including through the association's PricePoint tool, which helps estimate costs of services at different hospitals, by following state law that requires an estimated cost for elective procedures be given to any patient who requests it and by posting information about payment assistance online.
"We've done a lot to be transparent," Walker said. "We encourage consumers to be informed and arm themselves with information."
The SCC is accepting public comment about the regulations through Aug. 9. If approved, they will go into effect Oct. 1.
A radiology technician looks at a chest X-ray of a child suffering from flu symptoms at Upson Regional Medical Center in Thomaston, Ga.
The Associated Press
A radiology technician looks at a chest X-ray of a child suffering from flu symptoms at Upson Regional Medical Center in Thomaston, Ga.
The Associated Press
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