Gasline Newsletter August 2006

Volume 8, No. 3

Important Balance Billing Information for CSA Members

Withdrawal within one day after filing of the proposed emergency regulation banning balance billing for emergency services is only the latest development in a long running controversy. Today DMHC disclosed to CMA that it plans to propose very soon a three-point package of proposed regulations. In general terms, the regulations will propose:

banning balance billing apparently not limited to emergency services;
establishing an independent dispute resolution system with a modified “baseball" arbitration approach;
revising the Gould criteria presently used to determine "reasonableness" of reimbursement for non-contracted services.
This effort will not be on an emergency basis but will be under the standard process set by the Administrative Procedures Act (APA), meaning 45-day notice of specific language and public hearing, comment period and other steps. DMHC is hoping to aggressively push the APA process to have the regs finalized within 120 days. More details as to specific language, rationale and timing soon will be forthcoming.

A number of specialty societies, including CSA, are working with the CMA to contest the package. Discussions of coordinated political, legislative and judicial strategies are underway and will continue through the weekend.

Legal Counsel for CMA already had started work on filing suit against the emergency proposal and much of that effort can be applied to the next package. The comment period will offer an opportunity for specialty societies, practice groups and individual physicians to explain on the public record the adverse consequences of the proposals to their patients and their practices. Sample, or template, letters and talking points will be developed to assist interested parties.

A major turning point may be at hand in the fight to preserve the ability to obtain reasonable reimbursement for non-contracted services, or "balance billing," as it is known in the Capitol and described by DMHC. Pertinent legislation has stalemated the last several years while court rulings have thus far upheld the legality of balance billing. The Prospect case now before the State Supreme Court could also have an important impact on the current situation.

CMA's strong defense of balance billing was instrumental in the withdrawal of the emergency regulation and it is providing leadership in organizing opposition to the next and every bit as damaging regulatory package. CSA will be doing its part.