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Sacramento, Calif – Emergency physicians in California are hopping mad about new regulatory restrictions that ban their ability to recoup underpayments from health maintenance organizations by billing patients for the unpaid balance, a practice known as “balance billing.”

Last month, California became the latest state to impose a ban on the practice by specifically targeting patients who were billed for services received in the emergency department. The current restriction does not affect other forms of hospital care.

In issuing the ban, the state’s Department of Managed Health Care said it was protecting patients from being billed twice, first in the form of their premiums and secondly in being required to pay the unpaid balances on their bills.

William Mallon, MD, president of the California chapter of the American College of Emergency Physicians in Sacramento, blasted the regulation claiming it unfairly blames providers for the problem and leaves HMOs off the hook. “We’re not happy to be billing the patient. But we think HMOs should pay the full freight,” Mallon says.

The restriction does nothing to address non-contracted HMOs, Mallon said. It frees those payers from any responsibility over any part of a claim submitted by a non-contracting provider, Mallon added. Hospital’s EDs are prohibited by EMTALA from denying care to patients on the basis of their ability to pay.

Despite the growth of point-of-service plans and preferred provider organizations that pay non-contracting providers, California EPs realize a loss each year of between $130,000 and $150,000 in personal income stemming from indigent and non-contracted HMO care. One in seven ED visits involves a non-contracted HMO patient, according to CAL/ACEP. “The simple solution,” says Mallon, “is to make the non-contracting HMOs pay.” 

Eleven other states, including Colorado, New Jersey, and Maryland have recently implemented their own balance billing restrictions.

William Mallon, MD (right), president of the California chapter of ACEP, blasted the regulation, claiming it unfairly blames providers for the problem and leaves HMOs off the hook.
 

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