California and Balance Billing

This goes back to the situation with Prime Health Care hospitals. Prime owns several hospitals in California and does not have contracts with the insurance companies, and has the ER rooms to accommodate all. When the insurer pays what they feel is owed and the charges go beyond this amount, this is where the balance due comes in. You can read more here.

There are even issues between hospitals, with one suing another for not paying what is the "correct" or "contracted" amount that goes beyond the Prime situation. We seem to have our full share of those in California. Also, some of the hospitals purchased by Prime were on the verge of insolvency as well, so here we go, if Prime had not purchased and revamped their operations, would they still be around today? Again, this is not taking sides with either one, but more or less pondering a few questions here.

The patients though on the balance billing should not be placed in the middle and the insurers, hospitals, etc. should hopefully be able to get their act together on these issues. Some hospitals are auctioning out their receivables, so once more is it the patient who gets sick and needs care to be put on the block to pay when resources are not there and be one more candidate for bankruptcy? Nobody is winning any time soon at this game. BD

This is a brute-force political tactic by the insurer's lobby to impose de facto price controls on the health care market for ER services. Typically, ER doctors contract with HMOs or insurers in a free-market arrangement to agree on a fixed price for services to ER patients, usually at a substantial discount from the out-of network rate. In these cases, the insurer pays the bulk of the ER doctor's fee, and the patient is only responsible for their co-pay. However, if the HMO does not offer adequate compensation, the ER docs may opt not to contract, becoming "out of network" physicians, and in that case the patient is responsible for the balance of the ER doctor's fee after whatever arbitrary amount the insurer pays.

Movin' Meat: California and Balance Billing