The California Supreme Court on Balance Billing and Healthcare Providers

Amber Wheat

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I first heard of balance billing from my mother. I had gone to a doctors appointment, I paid my co-pay, and a couple of weeks later, I got a bill from their office. I asked my mom why I was being charged more money when I already paid my co-pay. “Isn’t the health insurance supposed to pay for the rest?”

We took a look at my statement and, sure enough, the insurance had paid for fifty-five percent of the bill. My mother told me that I may or may not be responsible for the difference in what the doctor thinks he’s owed and the price agreed upon in the contract between the insurance company and the doctor’s medical group. We looked up my policy and because of the type of visit, I was responsible for the balance.

That was my first run-in with balance billing. Then I read a very disturbing article from the Wall Street Journal about how emergency physicians and hospitals are balance billing customers who are not responsible for the charges. This is being practiced throughout the U.S. and many people don’t know that they don’t have to pay. It really depends on your insurance plan. But when it happens, the patients have to not only battle the doctors, but the insurance company as well. People are getting taken advantage of. Emergency patients are often not in any shape to be asking questions and confirming that the doctors who are trying to save their lives are in their networks.

As a legal assistant, I know all too well how expensive some of these emergency visits can get, especially in certain parts of California. Thankfully, California regulators recently made balance billing illegal if the charges were for emergency services and the patient is insured. The California Supreme Court backed up the new regulations in a court ruling that stated “Emergency room doctors may not bill the patient for the disputed amount.” If they want their money, they will have to fight with the insurance company. Fair enough, isn’t that why we have health insurance, so we don’t have to deal with conflicts like this?

There is, of course, a catch. Physician groups are worried about medical care providers who don’t sign up with insurance networks. It is true that they have every right to choose not to contract with health insurance, but does that mean they are precluded from billing insured patients at all? Doctors work hard and hospitals cost money (they don’t grow on trees). Insurance networks only pay a small percentage of what the out-of-network doctor bills (remember the fifty-five percent). How would you like to only get paid half of what you thought you earned?

The New York attorney general’s office is currently involved in an investigation as to how the insurance companies come up with what is a reasonable-and-customary fee. I am truly interested in this because I wonder how much health care really costs. Should doctors really get paid $200 for spending fifteen minutes with me?

Maybe Kaiser has the right idea. An insurance company with their own doctors and hospitals. It seems like a conflict of interest to me, but I still don’t fully understand the relationship between health insurers and healthcare providers. At least with Kaiser, you can be fairly certain that all the doctors are in-network.