Lawmakers asked insurers and doctors to find a solution on balance billing. They didn’t, and neither have lawmakers.

By: - January 18, 2019 5:01 am

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The struggle over balance billing spilled into lawmakers laps on Thursday, leaving them to tussle over who should have to pay the bills that would otherwise go to patients. And they didn’t get far.

Balance billing occurs when patients, usually unknowingly, gets a bill from a provider that they thought was in-network and covered by their health plan. The most egregious occurrence is in the emergency room, when patients are rarely in a position to make sure their doctor is in-network, even if the hospital is.

Insurance company representatives and doctors’ groups were told by the Health Insurance Reform Commission to come up with a solution, or lawmakers would. They didn’t, and lawmakers haven’t seem to have had much luck coming up with a solution, either.

The insurers and doctors agreed that the patient shouldn’t be balance billed, but couldn’t agree on how doctors should ultimately be paid when they provide services to an out-of-network patient. Two bills presented to the House Commerce and Labor subcommittee on Thursday, sponsored by Dels. Kathy Byron, R-Bedford, and R. Lee Ware, R-Powhatan, offer two conflicting options.

“Everyone has really been trying to come together with a reasonable solution,” Byron said. “But of course when it deals with money, that’s always difficult to do because no one wants to let go too much. However, there have been some solutions that have come to the table. The question is: How much is it going to cost everyone?”

Ware is carrying the physicians’ bill, and several medical groups expressed their support for it. Under the terms of his bill, the doctors would be paid the average of similar payments in their region, according to information gathered from Virginia Health Information, which has data on how much services cost.

“We were trying to find something that’s more transparent when we were developing the language in our bill, something that was verified and less opaque,” said Dr. Trisha Anest, an emergency room physician and member of the Virginia College of Emergency Physicians. “This bill makes sure that physicians are still getting fair and adequate payment so our emergency rooms stay staffed.”

The insurance companies were adamantly opposed to that option, though. Doug Gray, executive director of the Virginia Association of Health Plans, argued that doctors would be paid more under the calculation in Ware’s bill because, by using the regional average, the calculation would include networks that are paid more by the insurance companies because they offer more volume.

“Del. Ware’s bill basically gives providers a raise and an incentive to leave the network and stay out,” Gray said. “I don’t know why you’d ever join a network if you got paid more for being out of it than for being in it.”

He argued that the patient would ultimately bear the cost of paying physicians more because insurance companies would offset those charges in premiums.

By contrast, Byron’s bill would pay the doctors based on the average rate that the insurance company has already negotiated with other providers. It’s supported by the Virginia Association of Health Plans and several other groups representing insurance companies, who say the bill allows them to continue to create viable networks.

That payment option, though, doesn’t sit well with doctors’ groups.

“You leave all the determination of payment in the hands, largely, of the insurance company,” said Scott Johnson, a representative of the Medical Society of Virginia. “The ability of the providers to negotiate a fair in-network rate is going to be tilted in favor of the insurance company.”

Ultimately, lawmakers on the committee hit the same roadblocks that insurers and providers couldn’t overcome. They didn’t sift through the arguments and make their own decision on how the payments should be negotiated.  Instead, Del. Terry Kilgore, R-Scott, suggested moving the bills to the full Commerce and Labor Committee and, in the meantime, giving the relevant parties more time to try and come to an agreement on their own.

Byron urged against that option.

“I don’t want to be disingenuous by you thinking there’s going to be some great compromise here,” she said. “There’s two different solutions. I find it hard, after six months, to think that there’s going to be something where we all of a sudden have a ‘Kumbaya’ moment. Now, if you want more lobbyists to come out and visit you, that will happen.”

But the subcommittee ultimately agreed to move both bills to the full committee.

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Katie O'Connor
Katie O'Connor

Katie, a Manassas native, has covered health care, commercial real estate, law, agriculture and tourism for the Richmond Times-Dispatch, Richmond BizSense and the Northern Virginia Daily. Last year, she was named an Association of Health Care Journalists Regional Health Journalism Fellow, a program to aid journalists in making national health stories local and using data in their reporting. She is a graduate of the College of William and Mary, where she was executive editor of The Flat Hat, the college paper, and editor-in-chief of The Gallery, the college’s literary magazine.