In recent years, a number of Mainers have been hit with unexpected medical bills for services they believed would be covered under their insurance policies. Since a new law took effect in January, Mainers who unknowingly receive care from an out-of-network provider are protected against such billing practices.
Some in the health care system say the problem of “surprise billing,” or “balance billing” as it is known in the medical industry, is relatively small in Maine and that the new law is an overreach. But for consumers like Hancock County resident Christine Lutz-Garrity, hard-hit by costly medical bills they didn’t expect, the law comes as a relief.
In 2014, before purchasing a health insurance policy through Maine’s online marketplace, Lutz-Garrity used the internet to be sure the plan she was interested in included her current health care provider in its network of preferred providers. In written testimony provided last May to the Maine Legislature’s Joint Standing Committee on Insurance and Financial Services, Lutz-Garrity said she found her provider’s name on the company’s network directory, so she went ahead and purchased the insurance.
The committee was taking public comment on LD 1557, An Act to Protect Maine Consumers from Unexpected Medical Bills.
Lutz-Garrity’s due diligence didn’t pay off. It turned out that her provider had not actually been added to the insurance network, despite appearing in the directory. As a result, Lutz-Garrity was billed at the full, out-of-pocket rate for her first three visits before realizing there was a problem.
“I was billed for hundreds of dollars of appointments that, under my plan, should have cost me [nothing],” she told the committee. It took a full year of frustrating phone calls between Lutz-Garity, her insurance company and her health care provider, to resolve the situation
“It should not have happened that way,” she said. “If people like me cannot rely on the information we are given, then how are we supposed to be informed consumers? How are we supposed to know who’s in-network or out-of-network?”
Maine law already requires that insurers pay for emergency services provided out of network, as well as for specialty care when no network specialist is located within a geographic region.
The new law requires insurers to pay out-of-network providers when, like Lutz-Garrity, a patient has every reason to believe their provider is in-network and will be paid by their insurer.
It prevents providers from billing patients for the difference between what the insurance company pays and what they would otherwise charge and requires providers to work out payment disputes directly with insurers, not with patients.
It also calls for Maine insurance companies to provide “a current and accurate” provider directory for each plan, to be posted online and updated at least monthly. Print copies of the current provider list must be provided on request.
The original legislation was drafted with guidance from the nonprofit Maine Consumers for Affordable Health Care, which lobbies for consumer-friendly health policy and also provides free consumer assistance. The hotline receives frequent calls from Mainers who have been billed for services they believe should be covered by their insurance, a spokeswoman told the Bangor Daily News last week.
It took months for the bill to work its way through the committee process, according to the bill’s sponsor, independent Rep. Martin Grohman of Biddeford.
“Everyone hated it right out of the gate,” he said. But “there wasn’t anybody who didn’t think we should fix [the problem].” The bill underwent substantial revision with input from groups representing hospitals, insurers and physicians, as well as consumers. In the end, the amended bill won the unanimous endorsement of the insurance committee and went on for approval by the full legislature.
Midway through the committee process, Grohman said, his commitment to finding a fix was energized by a personal experience with surprise billing. When his 11-year-old daughter injured her arm on the backyard trampoline, an X-ray at the nearest urgent-care clinic confirmed a broken bone — and resulted in an out-of-network radiology bill for several hundred dollars.
The clinic was in his insurance network, Grohman said, but he had been in no mood to inquire whether the radiologist was in-network.
“In that moment of stress, all you want to know is, is it broken or is it not broken?” he said.
In Maine, most walk-in clinics, hospitals and other facilities that deliver health care participate with many, if not most, insurance plans doing business in the state. But, as Grohman learned the hard way, not all providers who work inside those facilities participate in the same networks.
Specialty services such as anesthesiology, radiology and pathology are often contracted to private provider groups that make their own arrangements with insurers. As a result, these contracted services are often the ones that bill patients for out-of-network services.
David Landry, CEO of Spectrum Healthcare Partners, which provides these and other contracted services to many Maine hospitals, said in an email last week that the new law addresses an “obscure issue” that is more common in other parts of the country than in Maine.
“In Maine, this really is not an issue, at least in my experience,” Landry told the BDN. “I am sure that there are anecdotal examples of when this might happen but certainly not a common practice.”
Landry said Spectrum participates with most insurers in Maine and that in cases where a patient unknowingly receives care out of network, “we would work with the patient and/or their insurer to obtain coverage for our services.”
At least 21 other states have enacted laws that protect patients from being billed for such services, according to a 2017 study form the Commonwealth Fund. Landry said national physician groups are concerned about the trend, in part because “it creates greater power and consolidation with the health insurers over the providers.”
At the Maine Association for Health Plans, executive director Katherine Pelletreau also opposed the original bill but dropped that opposition as the proposal was amended.
“We didn’t really see the need for this legislation,” she said. “From the health plan perspective, surprise billing has not been a huge issue in Maine.” Mainers who are uncertain whether a particular provider or service is covered in their plan need only contact their insurance company directly to find the answer, Pelletreau said, as well as a breakdown of the charges they will be responsible for.
Mainers with insurance-related questions or complaints may also contact the consumer division of the Maine Bureau of Insurance by emailing Insurance.PFR@maine.gov or phoning (800) 330-5000. Assistance is also available from Maine Consumers for Affordable Health Care by calling (800) 965-7476.
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