Penn. Commissioner Proposes Measures to Stop Surprise Medical Bills

January 20, 2016

Pennsylvania Insurance Commissioner Teresa Miller has announced a proposal to protect health care consumers from surprise balance bills and is soliciting public comment.

Surprise balance bills happen when a consumer receives emergency care or has made a good faith effort to use health care providers and facilities in the consumer’s health insurance network, but has unexpectedly received a service from a provider or at a facility that is out-of-network, then receives a bill for that service.

“At a public hearing in October, I heard from consumers who, despite their best efforts to use providers in their health insurance network, still received out-of-network bills that were in the hundreds — and in some cases thousands — of dollars,” Miller said.

Miller said the goal of this proposal is to take consumers out of billing disputes between insurers and health care providers. The measures would need to be adopted through state legislation.

She said the Pennsylvania Insurance Department looks forward to working collaboratively with the General Assembly, consumers, and stakeholder groups to draft legislation on this issue.

“As I said at the public hearing, when an individual is faced with a major medical issue, that person needs to concentrate on getting well, and not worry about whether an unexpected medical bill is coming in tomorrow’s mail,” Miller said.

The proposed plan would protect consumers who seek health care at in-network facilities, or from in-network providers, from being billed by an out-of-network provider at a cost more than what they would owe to a provider for any in-network cost sharing under the consumer’s health plan.

For example, if a consumer’s health insurance plan has a $50 co-pay for a certain service delivered by an in-network provider, that consumer would not be liable for more than $50 for that same service from an out-of-network provider.

The proposal provides several options for insurers and health care providers to reach agreement on payment. If the provider and insurer cannot reach an agreement on payment, the matter would go to arbitration.

Both sides would submit their offers with supporting documentation, and the arbitrator’s decision would be binding. In no case would the consumer be liable for anything beyond the cost-sharing due for the service if it had been rendered by an in-network provider.

Miller said the open comment process would allow the Insurance Department to get input from various stakeholders, including insurers, hospitals, and health care providers, all of whom also testified at the Department’s public hearing on this topic in October.

A link to the proposal and information on how to offer comments can be found at the Department’s website, The deadline for offering comments is Feb. 29, 2016.

Source: The Pennsylvania Insurance Department


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