PHOENIX — It won't stop unexpected medical bills.
But legislation approved Wednesday by the Senate is designed to give Arizonans a chance to fight having to pay them.
Sen. Debbie Lesko, R-Peoria, said SB 1441 will help with situations where someone goes into the hospital.
“If it's a scheduled procedure they have gone in to make sure that the doctor takes their insurance, they've checked to make sure the hospital takes their insurance and they think they're all set,” she said.
“A month later they get a bill from a doctor that's out of network,” Lesko said. “And they had no control over it.”
The most common situation, she said, is that a hospital has contracted with an anesthesiologist. But not being an employee of the hospital, that person submits a separate bill to the patient.
Under current law, Lesko explained, the patient has nowhere to turn as the doctor wants his or her money and the insurance company says it won't pay.
SB 1414 does not automatically excuse the patient from that balance billing. Instead, it sets up a procedure for people to ask the Department of Insurance to intervene and determine what's really a fair charge.
It would not apply in all situations.
State intervention would be available in cases where the service was provided in an emergency situation and the patient had no way to check which doctors are within his or her network.
For other situations, arbitration is available if the health care provider did not tell the patient up front that it is not within the patient's insurance network, did not provide the estimated total cost to be billed, and did not give the patient a chance to waive any rights to dispute the bill.
“If they receive a surprise medical bill they would call the Department of Insurance,” Lesko explained. That agency would set up a phone call involving the doctor, the insurance company and the patient.
Lesko said the experience elsewhere in states with similar systems leads her to believe that will resolve most problems.
“In Texas, 94 percent of all the complaints are settled over the phone,” she said. “They settle on the amount and it's over.”
Lesko said the way her legislation is crafted, the patient in most situations would be responsible only for the normal co-pay and deductible.
“And they're not going to be charged anything else,” she said.
Still, not all cases settle that way.
Those go to private arbitration, with the insurance company and the doctor splitting the cost of that process. And if either side disagreed with that finding, an appeal to court remains an option.
None of that is available, though, if the patient agrees ahead of time to a specific out-of-network cost.
“And if the patient signs that, agreeing to that amount, this whole process doesn't apply,” Lesko said. “There would be no settlement.”
But if the actual bill ends up more than that estimate, she said, then the review process would still apply.
Lesko acknowledged that an argument could be made that a patient should have to pay nothing if he or she has not agreed to out-of-network treatment and suddenly gets a bill. But she said such a proposal would never get approval because of opposition from doctors.
“We have to get a bill that has a good amount of consensus to go forward,” Lesko explained.
Whether she has it at this point, however, remains to be seen.
Despite the 25-5 vote on Wednesday doctors are still lobbying to kill the measure, at least in the form it's in. And they convinced several senators to oppose what Lesko wants.
Sen. Sylvia Allen, R-Snowflake, said she does not see SB 1441 as a balanced solution. She said there already is a great deal of pressure on doctors to cut their bills.
And Sen. Kate Brophy McGee, R-Phoenix, said she fears that at some point the pressures of measures like this will result in some doctors simply deciding they don't want to work at hospitals for fear they won't get their full bills paid.
“When you or a loved one are wheeled into that emergency room, the anesthesiologist, the emergency room doc, the trauma specialist, the trauma surgeon, they're not the bad guys,” Brophy McGee said.
“We pay them to be there, we expect them to be there, we expect them to put our lives back together,” she continued. “Depending on how we approach this issue and how we address it, they won't be.”
Lesko, however, said she was not focused on the concerns of medical providers.
“I'm doing this for patients,” she said. “I'm not doing this for the insurance companies, I'm not doing this for doctors, I'm not doing it for hospitals.”
Even if Lesko can get her bill through the House, where it now goes, none of this will help patients for the rest of this year or even next year. The legislation gives the Department of Insurance until 2019 to set up the rules and procedures for the review process.