CMA Trustees to Consider Balance Billing Pilot Project

[CAL/AAEM News Service]

CMA Trustees to Consider Balance Billing Pilot Project

Source: CMA Alert (http://www.calphys.org/html/news.asp) 
Date: July 21, 2005


CMA’s Board of Trustees at its next meeting will consider a proposal to create three
concurrent pilot programs that would test different methods of resolving billing disputes
between health plans and noncontracting physicians.

Four years in a row, legislation has been introduced that would prohibit noncontracting
physicians from balance billing patients when health plans fail to pay fairly for
services provided to their enrollees. CMA strongly opposes the current health-plan backed
legislation. It would give insurers a free hand to pay noncontracted physicians as little
as possible and would also eliminate any incentive for the plans to contract with
physicians at fair rates. Nevertheless, CMA understands that patients do not want or
expect to be billed because their insurance companies don’t pay reasonable charges for
covered services.

While in previous years legislative authors have worked with CMA to address this problem,
this year we witnessed a blatant attempt by health plans to place physicians in a
completely vulnerable position by prohibiting balance billing without offering any
protections against unfair payments.

That bill (AB 1321 by Assemblyman Leland Yee, San Francisco) narrowly made it out of its
first committee. Although the bill has been held up, the debate revealed the public’s
anger and confusion about balance billing and the Legislature’s intent to do something
about it this year. Clearly, even CMA’s friends in the Legislature want a resolution.
With that prompting, CMA staff created several concepts that would protect noncontracted
physicians’ right to balance bill, while addressing the specific concerns that arise when
HMO patients are treated in hospital-based settings.

These limited pilot projects will be conducted over a period of years to assess the
viability of different dispute resolution mechanisms. These projects will be studied and
can be rejected if proven unmeritorious.

Two of the proposed pilot programs that the trustees will discuss would test
“baseball-style” arbitration, one with state oversight and one with local oversight. In
baseball arbitration, the arbiter considers competing proposals from each side and simply
chooses the most reasonable. The idea encourages the two sides to make reasonable offers
to avoid having their proposal eliminated as unrealistic. The third program would test
traditional arbitration overseen by a local medical society. After two to three years, a
neutral party would make a recommendation to the Legislature as to which of the three
worked best for all.

Many important details are yet to be decided, including who would pay for the
arbitration, what evidence can be introduced, and how much time the arbiter should be
allowed to take to render a decision. These and many other important details will have to
be debated, and even then the results are unpredictable. This uncertainty explains why
there is strong support for pilot programs. Because it is such an important matter to a
large number of physicians, no one is willing to endorse a single solution for the entire
state.

Members are encouraged to discuss this with their trustee prior to the July 29 meeting.

For more information, please visit http://www.calphys.org/html/bb936.asp 


Cyrus Shahpar & Brian Potts 
Managing Editors, CAL/AAEM News Service
University of California, Irvine

The CAL/AAEM Archives are available at: http://maillists.uci.edu/mailman/public/calaaem/



		
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