days Agenda Intro to Balance Billing Balance Bill Defined When is - - PowerPoint PPT Presentation

day’s Agenda

Intro to Balance Billing

• Balance Bill Defined
• When is it Required?

Industry Examples

• Calculating the Amount of a Balance Bill
• Health Plan Language in the Summary Plan Document
• Insurers Suing Providers

Relevant Case Studies

• Out‐of‐Network Cases – Fee Forgiveness
• Out‐of‐Network Cases – Excessive Fees
• Out‐of‐Network Cases – Assignment of Benefits
• Interesting New Law

Best Practices & Discussion

• Transparency & Disclosure
• Practice Management
• Q&A Discussion, Bonus Materials

What is a Balance Bill?

Most plans describe a Balance Bill as:

• The difference between the Maximum Allowed Amount

and Charges (Example below) Generally, contracted providers may not balance bill patients for covered services

Lack of BB Statute in Insurance Laws

• Confusion around whether it is required
• 99% of the time it is
• Surprise Bill Laws not helpful
• Most of these laws only apply to 5% of health plans
• Examples:
• New York
• New Jersey

Are you required to Balance

Bill? Yes!

• When patients sign up for health

insurance, they agree to pay deductibles, copayments and coinsurance

• Physicians cannot issue blanket waivers or

refuse to balance bill out‐of‐network patients

– Insurance audits and investigations – Civil and criminal liability

• Consumer fraud
• Insurance fraud
• Tortious interference with a business contract
• Unfair competition

F l Cl i A i l i

The Balance Billing Requirement

Balance Bill Example

$10,000 Total Charges $2,000 Maximum Allowed Amount $1,000 Patient Deductible Patient Responsibility (Charges – MAA) + Deductible ($10,000 ‐ $2,000) + $1,000 = $9,000 Balance Bill Amt

Requirement of BB in Health Plan Document Summary Plan Documents

“Balance billing — Balance billing happens after you’ve paid your deductible, coinsurance or copay and your insurance company has also paid everything it’s obligated to pay toward your medical bill. If there is still a balance owed on that bill and the doctor or hospital expects you to pay that balance, you’re being balance billed. If your doctor is out of network and charges more than the allowed amount fee, the plan won’t pay for any amount above the allowed amount. You’re responsible for paying this difference, which is shown

• n the explanation of benefits (EOB) you receive from your medical plan. If

you’re enrolled in one of the out‐of‐area plans, there’s no network of

• providers. You may use any licensed, eligible provider and receive the same

level of coverage. If your doctor charges more than the allowed amount fee, the plan won’t pay for any amount above the allowed amount level. You’re responsible for paying this difference.” Bank of America Summary Plan Document

“You also have the choice to access licensed providers, hospitals and facilities outside the network for covered services and supplies. Your out‐

• f‐pocket costs will generally be higher when you use out‐of‐network

providers because the deductibles, copayments, and payment percentage that you are required to pay are usually higher when you utilize out‐of‐ network providers. Out‐of‐network providers have not agreed to accept the negotiated charge and may balance bill you for charges over the amount Aetna pays under the plan.” CDHP Medical Summary Plan Document “When you receive covered services from an out‐of‐network Provider, you may also be responsible for paying any difference between the Maximum Allowed Amount and the Provider’s actual charges. This amount can be significant.” Ally Financial Inc. Summary Plan Document “Unlike in‐network providers, out‐of‐network providers may send you a bill and collect for the amount of the Provider’s charge that exceeds the Plan’s maximum allowable amount. You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Provider charges. This amount can be significant.” CareFirst BlueCross BlueShield Summary Plan Document

Failure to Balance Bill

Insurers Suing OON Practices

North Cypress Med. Ctr. Operating Co. v. Cigna Healthcare, 781 F.3d 182, 2015 U.S. App. LEXIS 3711, 59 Employee Benefits Cas. (BNA) 1905 (5th Cir. Tex. 2015) Arapahoe Surgery Ctr., LLC v. Cigna Healthcare, Inc., 2015 U.S. Dist. LEXIS 28375, 2015-1 Trade Cas. (CCH) P79,074 (D. Colo. Mar. 6, 2015) Cigna Healthcare v. Health Diagnostic Laboratory, Inc. Advanced Ambulatory Surgical Ctr., Inc. v. Cigna Healthcare of Illinois, 2014 U.S. Dist. LEXIS 138722 (N.D. Ill. Sept. 30, 2014)

• Mt. View Surgical Ctr. v. CIGNA Health Corp., 2013 U.S. Dist. LEXIS

173232, 2013 WL 6491159 (C.D. Cal. Dec. 10, 2013 See Attached Case Studies #1

Out-of-Network Fee Forgiveness Cases by Cigna

HCA HEALTH SERVICES V. AETNA LIFE INS. CO. 1994 U.S. Dist. LEXIS 6080 (E.D.Va.Mar. 4, 1994) Aetna v. Bay Area Surgical Mgmt.: 2012 Cal. Super. LEXIS 468 Aetna v. Huntingdon Valley Surgical Center: 2015 U.S. Dist. LEXIS 122488

See Attached Case Studies #2

Out-of-Network Fee Forgiveness Cases by Aetna

Garcia v. HealthNet: 2007 N.J. Superior. Court, Chancery Division, Bergen County Unpub. LEXIS 2995 Oxford v. Josephson: 2010 N.Y. Misc. LEXIS 3558 Supreme Court of New York, New York County , 2010 NY Slip Op 32014(U) United Healthcare v. Sanctuary Surgical: 5 F. Supp. 3d 1350, 2014 U.S. Dist. LEXIS 28824, 24 Fla. L. Weekly Fed. D 345 (S.D. Fla 2014) Biomed Pharms., Inc. v. Oxford Health Plans(NY), Inc., 522 Fed. Appx. 81, 82(2d Cir. 2013) | 56 Employee Benefits Cas. (BNA) 1627 | 2013 WL 2991293 Horizon Blue Cross Blue Shield of New Jersey v. East Brunswick Surgery Center, 623 F. Supp. 2d 568, 577 (D. N.J. 2009). See Attached Case Studies #3

Out-of-Network Forgiveness Cases By Other Health Plans

AETNA V. Humble Surgical Hospital CIVIL ACTION NO. 4:12-cv-1206 (Document 1 Filed in TXSD on 04/18/12) UnitedHealthcare Servs., Inc. v. Asprinio, 2015 N.Y. Misc. LEXIS 3165, 2015 NY Slip Op 25298, 16 N.Y.S.3d 139 (N.Y. Sup. Ct. 2015) United Healthcare v Karim A. Paracha, M.D., Index #07033/2014 – Suffolk County Supreme Court, New York. Decided September 16, 2015 See Attached Case Studies #4

Out-of-Network Excessive Fees Cases

Out-of-Network Assignment of Benefit Cases

North Jersey Brain & Spine Center v. Aetna, Inc. (US Court of Appeals 3rd Circuit decided September 11, 2015) New Jersey case where court ruled an out-of-network surgical center could sue a health plan directly despite anti-assignment clause in the Member’s Aetna plan. Spindex v. Physical Therapy (9th Circuit 2015) The 9th circuit court refused to permit an out-of-network facility to sue a health plan directly due to anti-assignment clauses contained in the Member’s United Health Plan. Bloom and Weather Vane Chiropractic, P.C. v Independence Blue Cross (E.D.P.A. 2015) The Eastern District of PA allowed an in-network provider to sue Blue Cross directly despite anti-assignment clause contained in member’s Blue Cross Health Plan. The anti-assignment clause covered the right for payment and not the right to sue under ERISA.

HMO’s May Not Terminate Physicians for Recommending Out of-Network Providers

Under a new Texas law, effective September 1, 2015, health maintenance organizations (HMO’s) can no longer terminate a physician from their networks solely because the physician informs his

• r her patient about the full range of available health care providers,

including out-of-network providers. Although physicians will have to make certain disclosures when referring a patient to an out-of-network provider, they no longer have to fear being terminated from the HMO network for doing so.

Interesting New Law

NYS Passes Surprise Bill Law Effective - April 1, 2015

Best Practices

Transparency and Disclosure

• List contracted health plans on website
• When patient schedules an appointment, indicate

whether physician participates in patient’s health plan

• Provide notice that physician cannot reduce or waive

any patient cost sharing requirement and patient will be financially responsible for costs not covered by insurer

• Prior to providing out‐of‐network, non‐emergency

care, inform patient of anticipated cost of care and advise that costs could go up if unforeseen circumstances arise

Practice Management

• Collect patient cost share at time of service
• Charity care and financial hardship policies

– Disclose any reduction or waiver of patient cost sharing when submitting claim to insurer

• Appeal denial of out‐of‐network claims at

least twice before billing patients

• Good faith effort to collect patient balances
• Have patient sign assignment forms,

acknowledgement of/consent to out‐of‐ network services