Balanced Billing, Isn’t

“You've paid your health care premiums. Beyond your co-pays and deductibles, you now receive a bill for “an additional $42 after getting stitches in the emergency room. This bill (called a ‘balance bill’) results from your health plan's refusal to pay an out-of-network emergency physician fairly for treating you.” Apparently, the emergency physician does not have a contract with your health plan and he or she has “repeatedly sent the plan a bill, which it has repeatedly refused to fairly pay. Now your health plan is passing this responsibility on to you.”

“This calculated practice of chronic underpayments and non-payments by health plans created balance billing in the first place, and the California Department of Managed Health Care has done little to prevent this unfair payment practice. The health plans have decided that your heart attack or your broken leg or your laceration is not as important as growing their profit margins. The health plans have decided to make their own enrollees responsible for paying twice (premiums and a balance bill), and then they villainize the physicians who care for their enrollees.”

The author, William K. Mallon, MD who is the President of the California Chapter of the American College of Emergency Physicians, continues: “ Let us not forget that these are the same health plans guilty of retroactively rescinding coverage on patients diagnosed with cancer, that regularly deny care and referral to their enrollees, all the while paying their CEOs millions.”

Clearly, this “balance billing” should be abolished, which will ensure reasonable payment for appropriate care, even for that provided by out-of-network physicians. Today in my pediatrics office, I encountered a health plan that would rather pay $400 for an ER visit for a shot of Decadron for croup, rather than me. Lsst week, an even more dramatic disparity of treatment for a laceration I repaired.

The above commentary, by the way took place in California where it is noted that “California is already last in the nation in the number of emergency- room beds per capita. No fewer than 70 emergency rooms have closed in California since 1996, with more teetering on the brink.” Proposed regulations “will simply further erode the safety net and make the nearest emergency room farther away.”

Emergency physicians want to get back to the business of saving lives and caring for Californians, not haggling with insurance bureaucrats about receiving fair payment.

The real problems are:

• Systematic, abusive payment patterns by health care plans.

• The failure of the department to regulate the plans on behalf of Californians and health care providers.

- William K. Mallon, MD (President of the California Chapter of the American College of Emergency Physicians). “My View: There's nothing balanced about 'balance bills.'” The Sacramento Bee (Sacramento, CA 95852), Main News Section, P. A21.