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Legislation curbs many surprise medical bills, not all

Surprise medical bills cascaded into the Hopkins household after Joey Hopkins, left, was airlifted to a hospital following a hiking accident. Joey later died without an estate but his dad Jim, right, fought for a year to get the bills paid anyway. Legislation passed by the Georgia Legislature in June 2020 looks as if it would prevent some bills like the ones Hopkins got, such as the hospital and doctor bills. It would not address others, such as the air ambulance. (PHOTO courtesy of Jim Hopkins)
Surprise medical bills cascaded into the Hopkins household after Joey Hopkins, left, was airlifted to a hospital following a hiking accident. Joey later died without an estate but his dad Jim, right, fought for a year to get the bills paid anyway. Legislation passed by the Georgia Legislature in June 2020 looks as if it would prevent some bills like the ones Hopkins got, such as the hospital and doctor bills. It would not address others, such as the air ambulance. (PHOTO courtesy of Jim Hopkins)

State lawmakers have passed legislation that could protect Georgians with individual insurance policies from massive, unexpected bills after emergency hospital visits.

Right now, residents who don’t get their insurance through big employers — and instead buy through the federal marketplace or insurance agents — have little recourse when they wind up with surprises in their bills.

Legislators are now taking a big whack at surprise billing with House Bill 888, which would ban some, though not all, surprise charges for insured patients. After years of talk and failure, both chambers of the General Assembly have passed the legislation. It now sits on the desk of Gov. Brian Kemp.

“It’s totally significant,” said Rep. Lee Hawkins, the Gainesville Republican who sponsored HB 888 in the House. The measure that passed would ban most surprise bills for emergency care, but not for non-emergency hospital charges. For non-emergency care, patients need to do their homework and find out what hospitals are in their network, he said.

“I’m very strong on patient choice,” Hawkins said. “What I’m not for is that surprising bill when a patient unknowingly is treated by someone and has no recourse other than maybe going into bankruptcy.”

The bill also would not apply to ambulance rides, either helicopter or ground transport.

It relies on the good faith of insurance companies and health care providers to agree when something meets the definition of an emergency, and to make it easy for patients to know who’s in their network as they choose care.

The legislation doesn’t apply to policyholders with employer-sponsored plans; those plans usually offer better protection than individual plans.

It also doesn't apply to voluntary "coverage" cooperatives known as health care sharing ministries, such as Medishare, which are not real insurance and are not regulated by the state.

A spokesman for the governor, Cody Hall, did not say outright that Kemp would sign the bill, but he noted surprise billing is an issue the governor fought to rein in.

“Families are living on a prayer because the system is rigged against them,” Kemp said in his State of the State address this year, promising to “craft a legislative remedy to reduce surprise medical billing.” As written, HB 888 would do just that, if the Department of Insurance is able to create the system the bill envisions for regulating prices and disputes.

Hall said the governor’s office now has the bill under legal review, which is standard practice before legislation is signed.

A long-standing problem

Surprise bills happen when a patient with proper insurance gets treatment from a facility or a health care worker who turns out to be not in their insurance company’s network.

Each insurance company has a network of facilities and providers that they’ve negotiated contracts with for agreed prices. Clinics, doctors and hospitals that haven’t signed contracts with that company are out of network. Some of out-of-network medical bills are unreasonably high, critics say.

Even if a patient is treated at an in-network hospital, that isn’t a guarantee that all the health care providers are, as well. For instance, the emergency room doctor, or anesthesiologist, or radiologist who evaluates the scans can be an independent contractor.

For Jason Doss, an attorney whose clients are suing the insurance giant Anthem, the bill would be “a step in the right direction,” he said, but one with big holes that would leave patients vulnerable.

While the bill defines what an emergency is, he noted, it doesn't say who makes the final call if there's a dispute about that with the patient. Anthem has a history of denying emergency claims from its policyholders, saying the patient's condition wasn't really an emergency.

“People go to the hospital all the time because it’s an emergency to them,” for instance, chest pains, Doss said. “So, if it later gets determined by an insurance company it’s not, then the risk is on the patient.”

And, there’s the issue of knowing who is and isn’t in network. Under the new legislation, a patient who’s referred to an out-of-network doctor would have to be informed orally and in writing of that fact and given an estimate of the cost. But when it comes to hospitals, the bill assumes the patient knows on their own.

Insurance companies’ lists of in-network providers aren’t always accurate. And sometimes they change. In 2019, Anthem dropped Wellstar from its individual plan network, and many policyholders only found out when they went to make appointments. All of Cobb County’s hospitals are Wellstar facilities. Doss represents clients with Anthem insurance plans who needed Wellstar hospitals and doctors and found themselves stranded.

HB 888 “assumes that the insurance company is telling the truth about which doctors and hospitals are in network and which ones are not,” Doss said. “That’s one big issue.”

Still, the new law could prove very useful for patients who receive emergency treatment. Any patient with an individual insurance plan could not be billed by the hospital or doctor for more than the regular co-pay or out-of-pocket fee.

Instead, the legislation would make the insurance company pay the doctor or hospital what they would normally pay for in-network services. The bill would have the state Department of Insurance maintain a price list of prices paid locally for particular services, and it would also have the department write rules to set up an arbitration system if the insurance companies and health care providers couldn’t work it out on their own. In such cases, the key element is that the patient would be out of the fight.

A representative for health insurance companies, Jesse Weathington, said that he expected the DOI to have the system up and running January 1, 2021.

“It took a lot of leadership to break the deadlock and get this bill passed,” he said. “It’s a win for consumers.”