Colorado lawmakers introduce bill to stop ‘surprise’ out-of-network medical billing

DENVER -- When Zoe Williams rushed her child via ambulance to Denver Health Medical Center a few years ago, she thought she was doing the right thing.

"On Sept. 1, 2016, I got the text message no one wants to get: my 3-year-old had fallen in a park and was injured," Williams said.

After first going to an in-network urgent care center, she followed her physician's advice and went to Denver Health for further care after learning her child may have a spine injury.

She thought she did everything right. However, one morning, she was awoken by a call from a debt collector.

"I start to do a little bit of digging and find that none of the bills have been paid -- we are $15,000 in debt," Williams said.

Williams was a victim of "surprise billing," which is when a doctor or medical professional who is in-network sends a patient to a hospital or provider who is out of network. The patient usually has no idea.

Thursday at the Colorado State Capitol, lawmakers introduced a bill to limit how much hospitals and medical professionals can charge in these circumstances. It would not change billing for patients who seek out "out-of-network" care.

"It's a loophole in our system that some people are making a lot of money on," State Senator Brittany Pettersen (D - Lakewood) said.

Pettersen, along with Republican Senator Bob Gardner, is a co-sponsor of the bill in the Colorado Senate.

The bill would limit how much could be charged to this:

  • 125 percent of Medicare's reimbursement rate
  • The average in-network rate for the geographical area
  • The average in-network rate as determined by the "All Payer Claims Database"

The bill would only apply to insurance plans regulated by the Colorado Division of Insurance. You can tell if your insurance card says "CO-DOI" on it. Congress would have to pass federal legislation for the rest of the country.

Lawmakers acknowledge this type of legislation has been proposed in the past. However, it was defeated after opposition in the medical community formed.

The Colorado Hospital Association tells FOX31 they have "serious concerns" with the legislation this evening:

"Colorado Hospital Association strongly supports ensuring that patients are informed of their rights and protected from unexpected financial consequences when they receive care.

Katherine Mulready, CHA senior vice president and chief strategy officer explained “The bill’s sponsors said today that they are looking for the ‘sweet spot’ that will bring consumers, carriers, providers and facilities to a compromise. CHA is completely aligned with the goal of this legislation, but we are concerned that the bill as introduced falls short.”

Setting a “default” payment rate for hospitals that are not in an insurer’s provider network will have ripple effects in the market if the default rate is too low.  In particular, hospitals may not be able to negotiate as effectively with insurance carriers to ensure fair payments for all of the essential services they provide.  Mulready said, “Colorado hospitals agree that the status quo is unsustainable, and hospitals are eager to work with the sponsors to find the desired ‘sweet spot,’ but we cannot shift the market so much that insurance companies lack incentives to fairly negotiate.”

Following on the precedent of the Association’s support for HB 19-1001, there is no doubt we can find a solution when all stakeholders commit to sitting down and working together. Colorado hospitals want to be part of the solution and are committed to working with all sides to develop a solution.

Colorado Hospital Association does not take formal positions on bills until they are introduced. As such, the Association is still assessing the proposed legislation, but has several concerns."

AlertMe
Notice: you are using an outdated browser. Microsoft does not recommend using IE as your default browser. Some features on this website, like video and images, might not work properly. For the best experience, please upgrade your browser.