California radiologists oppose balance billing limitations

 - California

The California Radiological Society (CRS) has come out in opposition of a bill that would put new limitations on balance billing in California.

Balance billing—when a physician not contracted with a preferred provider benefit plan bills the patient for the difference between how much the plan pays and the amount the provider feels is adequate reimbursement—is prohibited under current California law for emergency services needed to stabilize a patient in the hospital setting.

In an effort to shield patients from disputes between providers and plans, Assembly Bill 533 would prevent physicians who are out of a patient’s network from billing that patient for care provided at an in-network facility. Instead, the patient would pay the non-participating provider as if they were in their network.

Assemblymember Rob Bonta first introduced AB 533 in February. It was approved by the California assembly, 69-1, on June 2 and is scheduled to be heard by the Senate Health Committee sometime in July.

The CRS put out an official statement that asked others who oppose the bill to contact members of the Senate Health Committee directly. The organization said it is in favor of removing the patient from the back-and-forth between health plans and out-of-network physicians, but this specific solution is “unacceptable” and “gives too much power to plans.”

“It’s a classic case of buyers and sellers having very different perspectives on what the value of a service is,” Bob Achermann, CRS executive director, told RadiologyBusiness.com in a phone interview.

Achermann said that the central issue is determining fair payment to a physician who isn’t under contract with the patient's insurer. When a patient is in need of care, Achermann said, you can’t always guarantee every physician they see will be a part of their network. This is especially tough in a high-pressure hospital setting, where on-call specialists are more common and there is little time to break down insurance plans.

“I work in healthcare, but I don’t think I’d be able to figure out, on the gurney going in the hospital, ‘who’s going to see me?’” Achermann said. “It’s just not doable. It’s doable elsewhere, outside the hospital setting, but a little more difficult within.”

Achermann and the CRS offer some alternative solutions to this issue, saying it’s important for physicians groups and lawmakers to compromise before anything becomes law.

For instance, the CRS suggests the use of an Independent Dispute Resolution Process (IDRP) to determine reasonable payment levels for completed services.

“We suggest using a baseball-style arbitration,” Achermann said. “The mediator looks at what the physician thinks is fair and what the plan thinks is fair and picks one or the other, not something in between.”

Achermann said he wants these conversations to continue and he has hope that a compromise can still be reached.

AB 533 has not received a great deal of mainstream media attention, but a Los Angeles Times editorial in May did call for lawmakers to pass the bill. Physician groups may be unhappy with the bill and want a better resolution, the editorial board wrote, but that “shouldn’t stop lawmakers from protecting the patients who are caught in the middle.”