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It’s becoming increasingly difficult for patients to protect themselves from surprise medical bills, and a Virginia legislative committee has the issue firmly in its crosshairs.

As health care costs rise, patients are being asked to shoulder more of the burden. Some of that comes from a practice known as balance billing, when an out-of-network provider bills the patient for whatever their insurance company won’t pay.

Often, however, patients don’t know providers aren’t covered. They could triple check that their surgeon is in network, but forget about the anesthesiologist. Or maybe they didn’t have time to ask their doctor if they were covered when they were rushed to the emergency room. Even if they had checked, chances are the doctor wouldn’t know.

But inevitably, a few weeks later, a bill will arrive in the mail.

“The problem I have with the balance bill is, who determines what those costs are, over and above what the insurance company would reimburse that doctor?” asked Sen. Frank Wagner, R-Virginia Beach, during a Virginia Health Insurance Reform Commission meeting Monday. “It’s up to the people who are sending you that bill to determine how much they charge you, and what recourse do you have other than to write the check?”

Virginia’s Bureau of Insurance has received 34 balance billing complaints since October, according to data presented during the commission’s meeting. Some of those cases come from emergency-room visits when the doctor was out of network, even though the hospital itself was in network, while others were from ancillary services such as labs or imaging tests.

But lawmakers noted that that number would probably be much higher if more people knew that they could turn to the Bureau of Insurance for help with a high bill.

“The collection agency doesn’t send you the Bureau of Insurance’s phone number,” said Del. Kathy Byron, R-Bedford. “Because the people I’ve heard from don’t know to call anybody else.”

Charges from out-of-network providers contribute to about a third of medical debt cases that non-elderly adults are struggling with, according to a survey conducted by the Kaiser Family Foundation and the New York Times.

Some states have laws protecting patients from balance billing, such as California, Connecticut, Florida, Illinois, Maryland and New York, while other states have laws in place that address a piece of the problem. Those range from prohibiting health systems from balance billing to requiring insurers to hold their members harmless, which means the patient isn’t liable for the charges.

No such laws exist in Virginia. In 2017 a bill that would have only allowed providers to balance bill when it is expressly agreed to by the insurer and the patient was stricken by its patron, Sen. Jill Vogel, R-Fauquier. And during this year’s session, a bill Byron introduced to address balance billing for ancillary services was continued to next year.

The Health Insurance Reform Commission heard from representatives from Virginia’s hospitals and health plans about balance billing in a roundtable discussion, during which each pointed fingers at the other.

Byron and Sen. Rosalyn Dance, D-Petersburg, grilled R. Brent Rawlings, vice president and general counsel with the Virginia Hospital and Healthcare Association, on what goes on in a hospital: How are patients supposed to know if their doctor is out-of-network even though they go to an in-network hospital and if physicians are careful to only order lab tests and other services from in-network providers?

Rawlings said that there is “a lot of back-and-forth” between the patient, physician and the health plan to stop the patient from falling out of network. But Dr. Trisha Anest, an emergency room physician with Bon Secours Mary Immaculate Hospital, said that she doesn’t know her patient’s insurance status because it is irrelevant.

“I will take care of every member of my community that comes through those doors to the best of my ability regardless of their insurance status,” she said. “Insurance companies are aware that this is how emergency physicians operate. It takes all negotiating leverage out from under us.”

Doug Gray, executive director of the Virginia Association of Health Plans, argued that, in many parts of the state, hospitals have a monopoly on the services they offer, and if the insurance company cannot get the hospital to contract with them, the patients will be exposed to balance billing.

“Part of the challenge we have here is that providers aren’t taking responsibility for what happens inside their doors,” Gray said. “Is it willful to not be in network? Sure it is. It’s a willful act to try to increase your reimbursement.”

The discussion devolved into arguing, with people talking over each other. Julie McGarrh, a program director with Anthem, pointed out that even she is subject to balance billing, showing the lawmakers a bill she received for a single urinalysis that cost $3,687 — for a test she could have gotten from a drugstore for $50.

“This is once a month, and I’m still dealing with that, even as an executive at Anthem,” she said.

Wagner said that McGarrh’s example essentially added up to fraud.

“I’d be interested to know how many of those have been flipped over to collections agencies … and the next thing you know your credit’s destroyed,” he said. “Because somebody committed fraud against you, your credit’s destroyed.”

The roundtable discussion didn’t result in any substantial solutions that the state could take to fix the problem — but the lawmakers said they would address the situation one way or another.

“We have quite a serious problem on our hands that the consumers are having to deal with and it affects their lives, along with all the other changes that are going on in health care,” Byron said. “We’re looking for a solution. It may not be the one you want, so if you want to be at the table to be part of that solution, we’re asking you, now, to get engaged.”

Jill Hanken, a health care attorney with the Virginia Poverty Law Center, among other recommendations, suggested not letting an insurer change networks mid-year, thus catching the patient off guard, which Del. Eileen Filler-Corn, D-Fairfax, said could be a starting point.

Byron asked the Bureau of Insurance to work with stakeholders and develop some solutions to the problem by the commission’s next meeting in September.

Sen. Ryan McDougle, R-Hanover, said he’d like to see a menu of options to choose from during that next meeting and urged the industry to cooperate.

“I’d say the clock is ticking, and that clock has about a four-month expiration, and you’re going to see this group of legislators – Republicans and Democrats, House and Senate members – come up with a plan,” he said. “And once we’ve done that, I guarantee you, y’all will not like what we come up with.”