Bill Aiming To Rein In 'Balance Billing' Gets N.H. Senate Committee Endorsement

Apr 18, 2018

The Senate Health and Human Services Committee on Tuesday endorsed a proposal meant to protect patients from surprise out-of-network bills at in-network medical facilities — otherwise known as “balance billing.”

But that stamp of approval came only after several last-minute rounds of negotiations to respond to lingering concerns from lobbyists representing the state’s doctors and hospitals.

Several patients who had their own experience with these unexpected medical charges also showed up to urge Senators to endorse the bill — among them, Donna Beckman, whose story about unexpected charges after a visit to the Seabrook Emergency Room was at the center of an in-depth NHPR report on the issue earlier this year.

Read more: How 'Balance Billing' Can Blindside Patients With Unexpected Medical DebtCompany Known For Surprise E.R. Bills Expands in N.H.'s Healthcare Market

Beckman said that after going public with her story on social media and relaying it to NHPR, she’s been contacted by Sen. Claire McCaskill as part of an ongoing Congressional inquiry into the issue of balance billing nationwide.

Another patient, Allyson Ryder of North Hampton, told the committee about a similar situation stemming from the same Seabrook Emergency Room involved in Beckman's case.

As previously reported by NHPR, that Seabrook facility is one of several across New Hampshire that contracts with a national medical staffing company called EnVision Healthcare, which has come under scrutiny for its billing practices. 

Ryder said her wife went to the Seabrook Emergency Room last year after experiencing persistent abdominal pain. At the time, they feared she may have appendicitis — but it all checked out fine and required no intensive treatment.

“All said and done, for some IV fluids and ultrasounds and a shot of pain meds, it was almost $9,000,” Ryder said.

While they believed the visit would be covered by their insurance plan, Ryder said they later learned that wasn’t the case. They also realized, after doing their own research into the billing codes on the invoices they received, that they were being charged for the most expensive and intensive level of emergency treatment.

“I think the most upsetting part is the fact that we did go on the website of the American College of Emergency Physicians which does have guidelines for how you bill and code certain conditions, and they billed her at Level 5,” Ryder said. “She never came close to any of the symptoms you should be billing at that level for."

Instead of leaving patients like Ryder and her wife to deal with these charges, the bill on the table Tuesday sought to force health providers and insurers to work out payment disputes amongst themselves. House Bill 1809 only applies to a limited set of medical specialties — anesthesiology, radiology, emergency medicine and pathology services — but supporters said those seemed to be where patients most often ran into problems with unexpected out-of-network charges.

And for the most part, everyone at Tuesday’s hearing could at least agree on that central idea — holding patients harmless in situations where they tried to avoid, or had little way to object to, out-of-network charges.

The real issues arose when it came to deciding what should happen from there, particularly when it came to resolving pricing disagreements between insurance carriers and health providers.  

The version of HB1809 passed by the House said that the two sides should try to work things out on their own, but if they reach a stalemate they could ask the state insurance commissioner to weigh in. At that point, the commissioner would be able to tell the parties if their rates for a given procedure were “reasonable,” but he or she wouldn’t actually set a fixed price.

But lobbyists for the state’s hospitals and physicians’ groups — who have fought back bills to address balance billing several times before — weren’t happy with that outcome.

On Tuesday, they outlined their proposal for an amendment that would have required an additional round of “mediation” before sending these disputes to the insurance commissioner.

The two groups also wanted to come up with a list of mediators and to define, more clearly, what kind of criteria could be used for determining how much to pay for a given procedure.

The insurance department offered an amendment of their own that sought to appease some of the concerns raised by the hospitals and physicians, but didn’t get into as many specifics about how the mediation process would play out. At the same time, the department was already on board with the original bill and didn’t think the extra step was necessary to make it work.

After an hour of competing testimonies on this trio of potential paths forward, the prospect of finding something that everyone could agree on seemed elusive. Senate Majority Leader Jeb Bradley at one point referred to the situation as “a hot mess.”

“We have a House bill that some people can accept, but not everybody,” Bradley said. “We have a [New Hampshire Medical Society] and [New Hampshire Hospital Association] amendment that some people really don’t like. And we have an insurance department amendment that is, you know, like Goldilocks.”

To meet a legislative deadline, Bradley and the rest of the Senate committee needed to figure out which, if any, of those plans to endorse by the end of the day. But they also had other bills to deal with, too.

“So what I’m going to suggest is while we’re upstairs, the three bears get together and see if you can work it out in the next hour,” Bradley said, instructing the lobbyists, lawmakers and others who showed up to the hearing to work out their differences and bring him a compromise. “Find the right porridge.”

Those who had been working on the issue for months were under the impression they had already found that proverbial “porridge” — or at least something close to it.

A study committee spent the fall taking testimony from many of the same groups who were on hand for Tuesday’s hearing. That group came up with a plan that had the backing of the New Hampshire Insurance Department, Gov. Chris Sununu, patient advocates and insurance lobbyists.

While insurance representatives and patients both acknowledged that the bill wasn’t perfect — insurers weren’t thrilled with the process it spelled out for resolving pricing disputes, and patients weren’t thrilled that it only dealt with balance billing in certain specialties and settings — they viewed it as the best available option to take some incremental step forward.

Eventually, after two rounds of deliberations between lawmakers, healthcare lobbyists, the insurance department and others who’d been work-shopping the bill for the last several months, the group came up with something they were all comfortable presenting to the committee.

As a final compromise, the group suggested adding language to the bill that said the insurance department “may” require parties to engage in mediation before coming to them for a decision.

The text of this, and several other proposed changes, were not immediately available but are expected to be printed in the next Senate calendar.

After Tuesday’s marathon round of revisions and committee endorsement, the bill now heads to a vote before the full New Hampshire Senate.