ALERT: Georgia Passes State Legislation on Surprise Medical Bills and Balance Billing
by Adam Patterson, CADS
As discussed in previous articles, “Surprise Medical Bills” and “Balance Billing” have been recent hot topics. The U.S. House and Senate leaders recently passed legislation that would alter commercial insurance billing practices nationally. Georgia became one of many states to pass legislation that addresses this ongoing healthcare industry issue ahead of the Federal legislation.
Legislation Summary
Georgia recently passed two bills intended to protect Georgians from getting overwhelmed by unexpected medical bills. The first bill is Georgia General Assembly – HB 789 (ga.gov), which is named the Surprise Bill Transparency Act. This bill creates a surprise bill rating system based upon the number of certain physician specialty groups contracted with a hospital within a health insurer’s network. Although this bill will not directly impact Medicare part B ambulance providers, it adds a layer of accountability to the facilities we transport our patients to and from. The second bill, Georgia General Assembly – HB 888 (ga.gov), named the Surprise Billing Consumer Protection Act will directly impact EMS providers.
Main Provisions
Let’s review a couple of takeaways from these new laws.
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- Providers can only balance bill patients for co-insurance and deductibles regardless of whether they are in a participating provider agreement with the insurer.
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- Insurers are obligated to pay providers for medical services regardless of whether the EMS provider is in a participating provider agreement with the insurer.
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- The reimbursement amount is determined by an average of payments made (excluding Medicare and Medicaid) by payors for services during 2017.
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- If either the provider or insurer determines the payment amount to be insufficient, there is a new arbitration process that requires additional documentation. This process seems complicated with strict timelines.
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- There is strict terminology that prohibits credit reporting by nonparticipating providers for patients that do not pay deductibles, co-insurance, or co-payment.
Additionally, there are specific limitations with respect to what insurance plans the law applies to. There are several very specific plan types that are exempted from the Act, including air ambulance insurance, workers’ compensation, Medicare, Medicaid, and ERISA (self-insured) policies. Although air ambulances are listed as providers, there are questions about insurance policies, as well as protections under the Airline Deregulation Act (ADA).
Reaction
Most Georgia providers are familiar with insurance tactics to force participating provider agreements. Most recently, Blue Cross Blue Shield of Georgia (BCBS) leveraged service participating provider agreements to avoid paying benefits directly to the beneficiary. This law should provide protection from payors forcing participating provider agreements with below-market rates because insurers are now required to pay nonparticipating providers under the same rules as participating providers. Most providers would agree that having a collaborative approach with carriers to determine allowable amount can be beneficial to keep patients from incurring large bills for remaining balances. However, there is mixed feedback from EMS agencies that are not thrilled to have insurance carriers dictate provider rates.
The link below is to a previous article that takes a more in-depth look into the federal legislation that could supersede this state law. EMS is a small piece of the larger agenda. This change comes at a difficult time as most EMS providers are doing their best to navigate decreased call volumes and overtasked personnel. Most providers agreed that changes around Surprise Billing are needed, and although the timing is not ideal, it’s imperative that providers take into account the impact of this new law when completing their financial planning.
Adam is QMC’s Territory Sales Manager in the Southeast, he has 14 years of healthcare revenue cycle management experience and has worked with hundreds of ambulance services on formation, enrollment, revenue analysis & revenue cycle management. Additionally, he is a Certified Ambulance Documentation Specialist (CADS).
