Amid the healthcare misery of 2020, lawmakers in both the Georgia Legislature and Congress finally acted to curb surprise medical bills.
As of New Year’s Day, state law will protect hundreds of thousands of insured Georgia patients from being stuck with bills after emergency room visits. A year from now, the federal measure will extend protections against surprise medical bills to more than half the people in Georgia.
Both laws are a big step, following years when lawmakers retreated before powerful insurance companies and doctors’ groups that feared laws that could hinder them from making money.
“It’s about time,” said Jim Hopkins, who fought his son Joey’s ambulance and doctor bills after Joey died from a hiking accident. “I’m glad they passed the laws. It’s not right.”
What’s more, in another step to help Americans know in advance what healthcare will cost, starting Jan. 1 hospitals must post prices for many of their goods and services online.
Consumer advocates and public officials are celebrating the changes as long overdue.
“I think it’s a great thing,” said Rep. David Knight, R-Warner Robins, who has held hearings in the Legislature on the issue of surprise billing. “I think people are beginning to understand” how problematic the health care payment system is. “The better they understand it ...the more they want to see change in it.”
Still, the surprise billing laws and the price transparency rule leave gaps in consumer protection. The state and federal laws leave undone, for example, the problem of some ambulance rides not being covered by insurance. And hospitals are warning that the prices they are posting online may only confuse consumers.
Starting now: hospital price tags
The new price transparency rule that takes effect Friday came in response to an executive order by President Trump aimed at increasing transparency in the health care industry.
Astonishing increases in hospital prices have been a major driver of overall health care inflation. The same service that goes for a modest charge at a freestanding laboratory, for example, can cost many times that amount at a hospital laboratory.
Hospitals have resisted any kind of transparency around what individual facilities charge, though, citing the changeability of pricing depending on factors such as who is paying.
The rule requires hospitals to disclose privately negotiated charges with commercial health insurers.
A lobbyist for the Georgia Hospital Association, Ethan James, said Thursday that public release of the cost data could give large commercial health plans an unfair advantage in negotiations with hospitals, and insurers could pocket any savings, he said, rather than pass them along to consumers.
Hospital groups have sued over the rule, but a federal court on Dec. 29 rejected the legal challenge.
With the court ruling, some hospitals have already begun posting their prices, noting on their websites that the prices aren’t guaranteed.
James also noted that estimated costs could change as the course of treatment changes.
Another shortcoming: The listings don’t make it easy for patients to compare prices and figure out what the names of procedures mean. “Good luck with that,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.
Starting now: state steps on surprise billing
The Georgia General Assembly this spring passed House Bill 888, a first step toward banning surprise bills in the state.
Those bills most often happen when properly insured people go to a hospital, thinking thinking everything will be covered aside from their deductible, or a percentage of costs.
Yet up till now it has been legal for insurance to refuse to cover some costs, such as charges from a doctor who doesn’t have a contract with the insurer but works within a hospital that does. That doctor could legally bill the patient, and turn the account over to collections or sue if the patient doesn’t pay. The costs can be high.
They’re so high that private doctor groups have become a prize for private equity investors.
The problem in outlawing the practice has always been deciding how much the doctor or other service provider can charge if the insurance company has declined to sign a contract with them. Insurance companies are accused of wanting to pay prices so low doctors couldn’t stay afloat.
That disagreement will remain between the insurance company and the doctor or other health care provider; but Georgia’s new law takes the patient out of it.
The state will have a database of prices that insurers should pay, and if they don’t agree, there will be an arbitration process where the health care provider and the insurance company can fight it out and have the arbiter decide.
A lobbyist for Georgia health insurance plans, Jesse Weathington, called the bill “a win for consumers.” A lobbyist for the doctors, Derek Norton, called it “a win for Georgia patients.”
The law is just a first step because it has many gaps.
Georgia’s new law applies only to those who buy their insurance on the individual market. That’s several hundred thousand Georgians in any given year. It doesn’t apply to people with employer-sponsored insurance. And it doesn’t apply to ambulance rides.
It also relies on the good faith of insurance companies and health care providers to agree when something meets the definition of an emergency.
It allows surprise billing for non-emergency hospital visits if the patient signs a form acknowledging the possibility — even if the form is given as the patient arrives for their procedure.
In one more year: big federal changes
The federal law, tucked into the 5,500-page coronavirus relief bill signed by President Trump Sunday night, will take care of much of that.
Starting in 2022, surprise billing will be illegal not only for people who buy their insurance individually, but also for most of those on employer-sponsored plans. Altogether that’s more than half the people in Georgia.
The new law defines an emergency service as any service provided in an emergency room.
At that time, air ambulance rides for emergencies will have to be covered, too, though ground transport will not.
The federal law will have teeth. Service providers who illegally surprise bill can be fined up to $10,000.
“It’s a big deal,” Pollitz said. Surprise bills for the insured, she said, are just unfair. “Depending on the number and amount, they can cause a huge financial burden on families.”
Another new law: Georgia now has a state grape.
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