On June 17, 2020, the Georgia General Assembly passed legislation that is designed to curb unexpectedly high medical bills. Governor Brian Kemp is expected to sign the legislation, House Bill 888, into law. The bill requires insurers to cover emergency services regardless of whether the provider is in a patient’s insurance network. Medical providers and insurance companies will enter an arbitration process to determine the amount of reimbursement, effectively removing patients from the billing calculus.
These unexpectedly high medical bills, called “surprise” or “balance” billing, can add hundreds or thousands of dollars to a patient’s bill, often without the patient’s prior knowledge. Many of these bills result from specialty procedures like emergency room or trauma surgery and anesthesiology completed by out-of-network specialists.
Previous attempts at curbing these surprise bills have failed due to disagreements over how insurers and medical providers should settle out-of-network costs. However, representatives of the Georgia Hospital Association and the Medical Association of Georgia have supported House Bill 888.
How Out-of-Network Costs are Determined
The provider may only collect a patient’s deductible, coinsurance, copayment, or other cost-sharing amount, as provided by that patient’s insurance policy. The insurer will then pay the greater of:
- The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services;
- The most recent verifiable amount agreed to by the insurer and the nonparticipating provider for the provision of the same services during the time the provider was in-network with the insurer; or
- A higher amount that the insurer deems appropriate given the complexity and circumstances.
The amount paid by the insurer is not required to include any deductible, coinsurance, or copayment already paid by the patient.
The contracted amount is the median in-network amount paid during the 2017 calendar year by an insurer for the emergency or non-emergency services provided by in-network providers in the same or nearby geographic area. The contracted amount will be adjusted annually for inflation and will not include Medicare or Medicaid rates.
The Arbitration Process
The arbitration process will be available to out-of-network providers who believe they should be entitled to additional funds under certain provisions of the bill. These providers will have 30 days from receipt of payment to request arbitration. Arbitration requests may involve a single or multiple patients and a single or multiple types of healthcare services.
Please contact MMM’s healthcare group with any questions or for assistance.