The Wolf administration on Tuesday proposed strong consumer protections against surprise bills from providers outside patients' health insurance networks, tackling an issue that has swiftly gained prominence nationwide and largely eluded effective political solutions.
The proposal, which includes a 19-page draft bill - it has neither been introduced nor debated by lawmakers - removes consumers from disputes between providers and insurers over out-of-network bills, and requires both sides to agree to binding arbitration of disputes on a tight timeline or face hefty fines.
"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 today's mail," Pennsylvania Insurance Commissioner Teresa Miller said in a statement.
Surprise bills, sometimes called balance billing, have become a major consumer issue in just the last few years. A Consumer Reports survey last year found that nearly one-third of privately insured Americans reported receiving unexpected bills of all kinds.
Many arise from visits to emergency rooms in hospitals that may participate in the insurance company's network but employ emergency medicine doctors who do not. Another common scenario is when a patient schedules an operation with an in-network surgeon at an in-network hospital and discovers only when a bill arrives later that an out-of-network anesthesiologist had been part of the surgical team.
Patients report spending hours on the phone with hospitals, doctors' offices, and insurance representatives seeking resolution, but often are stuck with a bill that can run into thousands of dollars.
Several patients testified about their experiences at an October hearing that Miller held in Harrisburg.
Chuck Bell, who has worked on the issue for Consumers Union, also testified at the hearing. In an interview Tuesday, he said the new proposal, if adopted in its current form, would be among the strongest in the nation, primarily because it forces providers and insurers to agree.
Patients now have little power over either. Illinois and New York are the only states with laws that mandate independent dispute resolution, Bell said. Legislation in New Jersey that also would do that was rejected by a Senate committee last year.
"It really is an issue that requires cooperation from all sides," Bell said.
Sen. Jay Costa (D., Allegheny), the minority leader, said Tuesday evening that he had not seen the administration's proposal but believed the key points were similar to those in a cosponsorship memo that he and Sen. Judith Schwank (D., Berks) have been circulating. Costa said there was "some" bipartisan support.
Steve Miskin, a spokesman for the House Republican caucus, said that neither the health nor insurance committee chairs were aware of the proposal. Groups representing anesthesiologists and emergency medicine physicians, two specialties whose out-of-network members often are called without patients' knowledge, said they had not yet reviewed the proposal or couldn't be reached.
The Wolf administration's proposal sets a 30- to 90-day timeline for dispute resolution, with no avenue for appeals. It also forbids providers from referring patient bills to collection agencies.
The proposal is posted at www.insurance.pa.gov, where public comments may be submitted online.