Even when patients make concerted efforts to see doctors covered by their insurance plans at in-network facilities, they run the risk of unknowingly being treated by other out-of-network providers during that visit. A new state bill would protect people from paying hefty surprise medical bills stemming from such out-of-network charges.
The proposal, AB 72, says that when consumers are unknowingly treated by out-of-network radiologists, anesthesiologists or other providers, they would only pay what they would for doctors within their insurance network. These payments would also count towards their out-of-pocket maximums.
The legislation comes on the heels of an effort last year, AB 533, that was also intended to curb surprise out-of-network bills. That bill would have made consumers responsible only for in-network rates. Insurance companies would then have been required to reimburse the out-of-network doctors at the rate they would get from Medicare.
The California Medical Association and several other physicians groups opposed AB 533, mainly due to concerns about reimbursement. It failed by three votes on the Assembly floor on the final night of last year's legislative session.
The new proposal -- a result of compromise between lawmakers, insurers and advocates -- aims to address physicians' concerns by increasing the amount that insurance companies would pay out-of-network providers: It would be either 125 percent of the Medicare rate for the procedure or the average contracted rate for that region, whichever is greater.
"When AB 533 failed, that means we've now had months and months of California consumers getting unfair, surprise medical bills," said Anthony Wright, executive director of Health Access California, which is co-sponsoring the new legislation with the California Labor Federation. "We hope that AB 72 breaks the logjam and allows there to be a solution for patients who are doing exactly the right thing, but still getting these bills."
The California Medical Association is reviewing the new bill and hasn't taken a position on it yet, according to spokesman Griffin Rogers.
The new bill is co-authored by six Assembly members: Rob Bonta (D-Oakland,) Susan Bonilla (D-Concord,) Brian Dahle (R-Bieber,) Lorena Gonzalez (D-San Diego,) Brian Maienschein (R-San Diego) and Jim Wood (D-Healdsburg.) The Assembly Health Committee is slated to hear the bill on June 29.
Last year, a Consumer Reports National Research Center survey found that nearly one in four privately insured Californians who had hospital visits or surgery in the previous two years were charged an out-of-network rate when they thought their doctor was in-network.