Transparency legislation is latest effort to end surprise billing

Surprise medical bills have long puzzled – and angered – patients in Georgia and elsewhere.

This billing occurs when consumers have procedures or visit ERs at hospitals in their insurance network, then get separate bills for hundreds or even thousands of dollars from non-network doctors who were involved. These bills can come from ER doctors, anesthesiologists and radiologists, among others.

Several states recently have passed legislation to address the problem.

Georgia’s General Assembly will take another look at surprise billing this year, with new legislation sponsored by state Rep. Richard Smith, a Columbus Republican who has been a leading voice on the issue.

Smith proposed legislation on surprise billing in last year’s General Assembly session, but after much debate and revision, it ultimately died.

His new bill is quite different from the one he offered last year, which would have required that any doctor credentialed to work at a specific hospital be part of its insurance network.

“There’s more than one way to skin a cat,’’ Smith, chairman of the House Insurance Committee, told GHN on Tuesday.

He is trying with his new legislation to ensure the patient gets help making decisions through increased transparency of medical costs. Health care pricing, he said, “is like a black hole’’ for patients. But the legislation would appear to be not as comprehensive as what consumer groups have advocated in the past.


Under House Bill 678, a consumer getting non-emergency services from a hospital, physician practice or treatment facility would, upon request, receive information on whether the medical providers involved are in the patient’s insurance network, what the fees will be, and how much the patient’s policy will pay, Smith says.

The proposal would also require insurers to give information to members on obtaining a referral to a health care provider outside their network when the health plan does not have a provider in their geographic area. It would also make the insurer disclose the amount that would be reimbursed under out-of-network services.

Georgia Watch, a consumer advocacy group, praised the move for transparency regarding providers’ network status, and the requirement for better information for consumers to estimate out-of-pocket costs for planned procedures.

But Beth Stephens of Georgia Watch also said the bill “does not protect consumers in emergency situations or take consumers out of the middle of billing disputes that may arise over out-of-network charges.’’

“We appreciate Representative Smith’s continued attention to this problem and his effort to find a legislative solution, but we were hoping for a bill with more robust consumer protections,’’ Stephens said. “We will be closely watching how this legislation evolves over the course of the session.”


Georgia Watch has noted that a surprise bill can be the result of “balance billing.” This occurs when the patient is pursued for the balance after his or her health insurer pays its share to the medical provider. The problem is that the balance often turns out to be much more than the patient anticipated.

A huge bill for medical care can be an overwhelming load for a family. Medical debt is the No. 1 reason why consumers report being contacted by a collection agency, according to a report.

Groups’ first take on bill

Graham Thompson, executive director of the Georgia Association of Health Plans, an industry trade group, told GHN on Tuesday that his organization supports Smith’s new legislation. “On a planned procedure, [consumers] will be made aware of who’s in network and who’s out of network,’’ he said.

The legislation, if passed, would allow Georgians to make better choices with more information, Thompson added. “There are some real reforms’’ in the bill, he said.

Another provision in the new House legislation would require medical bills to be sent to patients within 90 days of discharge or of providing of the service.

The person responsible for payment would have 90 days afterward to secure payment, negotiate amounts or initiate arbitration. Only then would the provider or hospital be authorized to start formal collection efforts.

Under the proposal, arbitration could be initiated by the patient or person responsible for payment within the 90-day period by filing an application with the insurance commissioner, who would provide rules and procedures for handling the arbitration process.

Two medical provider groups expressed support for more pricing transparency. “We are supportive of transparency,’’ said Ethan James of the Georgia Hospital Association. “We want to make sure that consumers have tools to make decisions.’’

But James said Tuesday that GHA has some concerns over the arbitration provisions, as does the Medical Association of Georgia, a leading physicians organization.

MAG “supports much of what’s included in H.B. 678, especially when it comes to promoting greater transparency,’’ said the group’s government relations director, Derek Norton. “But we are still evaluating the bill and have some concerns related to pricing and arbitration that we are working through with legislators. MAG would ultimately like to see a more comprehensive solution.’’