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The California Association of Health Underwriters, Sacramento, is trying to protect members of managed care plans from huge, unexpected hospital charges.

CAHU is lobbying for Assembly Bill 2389, a measure that would require health plans and hospitals to include provisions for payment of most nonpreferred providers in preferred provider contracts.

The amended version of the bill would not apply to emergency room departments or ER doctors.

The California Society of Pathologists, Sacramento, is calling A.B. 2389 a forced contracting mandate. The California Healthcare Association, Sacramento, a major hospital trade group, also opposes the bill.

But the California Assembly Health Committee recently voted 14-1 to approve the bill.

CAHU is sponsoring the bill, which was written by Assembly member Paul Koretz, D-West Hollywood, Calif., because many CAHU members have heard complaints from insured consumers about receiving big bills from out-of-network anesthesiologists, radiologists, pathologists and other specialists who helped care for them while they were in in-network hospitals, CAHU says.

A few years ago, providers and carriers showed some willingness to help clear up payment problems involving out-of-network specialists, but, today, carriers are being tougher in applying out-of-network rates to doctors, says CAHU President Jeff Miles.

Meanwhile, the doctors billing people usually refuse to negotiate, and the doctors often dont know and dont care about the problems, Miles says.

The controversy focuses on a practice called balance billing.

Insurers and other companies that organize provider networks usually persuade participating doctors and hospital to charge patients who belong to the networks standard, discounted rates.

Providers who sign the contracts agree not to go after patients for the balance of the bill that happens to be above the networks negotiated rate.

But providers who treat out-of-network patients usually have a legal right to balance bill the patients, or go after the patients for any amounts left unpaid by the insurers.

In many cases, hospitals, out-of-network specialists and health plans all fail to warn patients about the possibility that out-of-network providers might end up balance billing them, CAHU says.


Reproduced from National Underwriter Edition, May 28, 2004. Copyright 2004 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.