Balance billing

Throughout the 1970s in Canada, the country saw an increase in balance billing, which in Canada is normally called extra billing. It was not permitted in Quebec or British Columbia, but had been encouraged in Ontario and Alberta, and tolerated in other provinces. The federal government estimated that by 1983, extra billing across Canada totaled $100 million. The government believed that extra billing enabled the creation of a two-tiered Canadian healthcare system, in which people who could not afford extra charges would receive lesser care.

In 1984, the government passed the Canada Health Act, which promised universal and comprehensive health coverage for all Canadians, and which contained provisions to discourage user fees and extra billing by imposing financial penalties on and reducing transfer payments to provinces that permitted them.{{cite book|last=McEwen|first=Nicola|title=Nationalism and the state: welfare and identity in Scotland and Quebec: Regionalism and Federalism|year=2006|publisher=P.I.E. Peter Lang SA|location=Brussels, Belgium|isbn=978-90-5201-240-7|pages=128–9|url=https://books.google.com/books?id=2aEDaSqNNkYC&q=%22extra+billing%22+canada&pg=PA128}}{{cite book|last=Dunn|first=Sheilagh M.|title=The year in review, 1982: intergovernmental relations in Canada|year=1982|publisher=Institute of Intergovernmental Relations|location=Kingston, Ontario|isbn=978-0-88911-038-0|pages=180–182|url=https://books.google.com/books?id=erH9eJ9kOzUC&q=%22extra+billing%22+canada&pg=PT180}} In 2002, five provinces prohibit all extra-billing, while Alberta, British Columbia (BC), and Newfoundland allow it in a small number of circumstances, and Prince Edward Island and New Brunswick do not restrict it at all.{{cite book|last=Sullivan|first=Terrence James, Patricia M. Baranek|title=First do no harm: making sense of Canadian health reform|year=2002|publisher=Malcolm Lester and Associates|location=Toronto, Ontario|isbn=978-0-7748-1016-6|pages=44|url=https://books.google.com/books?id=IvgplVyKfeYC&q=%22extra+billing%22+canada&pg=PA44}}

In 2003, the BC government enacted the Medicare Protection Amendment Act, which banned extra billing for medical services and diagnostic procedures deemed medically necessary and covered by the provincial Medicare system; however, many of the provisions were not enforced. In 2018, the government announced its intention to implement operational requirements more stringently and to impose financial penalties for extra billing for medically necessary diagnostic procedures. However, enforcement of medical procedures was delayed until after March 31, 2020, and diagnostic procedures until April 1, 2020, because of a court injunction in the case that would ultimately become Cambie Surgeries Corporation v. British Columbia.{{cite web |title=Update: Enforcement of Medicare Protection Act provisions (Bill 92) delayed one year |url=https://www.doctorsofbc.ca/news/update-enforcement-medicare-protection-act-provisions-bill-92-delayed-one-year |publisher=Doctors of BC |access-date=17 September 2022 |date=March 14, 2019}} On September 10, 2020, the Supreme Court of British Columbia dismissed the Cambrie plaintiffs' claims.{{Cite web| last = Weisgarber| first = Maria| title = B.C. Supreme Court rules against legalizing private health care following decade-long battle| work = British Columbia| access-date = 2020-09-10| date = 2020-09-10| url = https://bc.ctvnews.ca/b-c-supreme-court-rules-against-legalizing-private-health-care-following-decade-long-battle-1.5099737}} The plaintiffs filed a notice of appeal and in July 2022, the BC Court of Appeal upheld Justice Steeves' decision.{{Cite news| last = Woo| first = Andrea| title = B.C. Court of Appeal rules against doctor in private health care case| work = The Globe and Mail| access-date = September 10, 2022 | date = July 15, 2022 | url = https://www.theglobeandmail.com/canada/british-columbia/article-brian-day-private-health-care-ruling/}}{{cite web |last1=Van Horne |first1=Pat |title=BC Court of Appeal dismisses challenge to Medicare Protection Act |url=https://www.healthcoalition.ca/bc-court-of-appeal-dismisses-challenge-to-medicare-protection-act/ |publisher=Canadian Health Coalition |access-date=17 September 2022 |date=July 20, 2022}}

{{update|Federal No Surprises Act taking effect January 1, 2022 [https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2021/02/04/understanding-the-no-surprises-act/] and 33 state laws [https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections]|date=July 2021}}

Health insurance in the United States is typically provided by a managed care plan with a preferred or exclusive "network" of providers; balance billing does not occur with providers in-network, as the insurer negotiates an agreed rate ahead of the service.{{Cite web|url=https://www.healthinsurance.org/glossary/balance-billing/|title=balance billing definition|date=2017-09-05|website=healthinsurance.org|language=en|access-date=2019-04-16|quote=Providers that are in-network have agreed to accept the insurance payment as payment in full (less any applicable copays), and are not allowed to balance bill the patient.}} However, out-of-network medical billing has become common for privately insured patients even when they receive care in an in-network hospital, creating a substantial financial burden.{{cite journal | doi = 10.1001/jamainternmed.2019.3451 | pmid = 31403651 | pmc = 6692693 | title = Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals | journal = JAMA Internal Medicine | volume = 179 | issue = 11 | pages = 1543–1550 | year = 2019 | last1 = Sun | first1 = Eric C. | last2 = Mello | first2 = Michelle M. | last3 = Moshfegh | first3 = Jasmin | last4 = Baker | first4 = Laurence C. }} Surprise balance billing is when an out-of-network provider bills an individual for services that were not covered by the insurance plan. This is often a surprise because an individual may be unaware that the services were out-of-network or did not actively choose to receive in an inpatient setting. The "growing risk to patients of incurring burdensome unexpected out-of-network bills" has received significant attention in the 21st century.

Out-of-network care in the United States is very common and unavoidable in emergencies.{{Cite journal|last1=Garmon|first1=Christopher|last2=Chartock|first2=Benjamin|date=2017-01-01|title=One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills|journal=Health Affairs|volume=36|issue=1|pages=177–181|doi=10.1377/hlthaff.2016.0970|pmid=27974361|issn=0278-2715}}{{Cite journal|title=An examination of surprise medical bills and proposals to protect consumers from them|date=February 10, 2020|journal=Peterson-KFF Health System Tracker |author=Karen Pollitz |author2=Matthew Rae |author3=Gary Claxton |author4=Cynthia Cox |author5=Larry Levitt|url=https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them-3/}} A 2017 study published in Health Affairs concluded that in 2014, one in five inpatient emergency department causes will lead to surprise bills, and that 20% of emergency department admissions, 14% of outpatient visits to the emergency department, and 9% of elective inpatient admissions likely incurred a surprise medical bill. A 2020 Peterson-KFF Health System Tracker found that, "for people in large employer plans, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge associated with the care in 2017." However, surprise billing also occurs in planned-care (non-emergency) settings: for example, when a patient receives care at an in-network hospital or ambulatory surgery center, only to subsequently learn that a specific provider or providers providing the treatment (such as an anesthesiologist or radiologist) does not participate in the network of the patient's health plan. In both circumstances, "the patient is not in a position to choose the provider or to determine that provider's insurance network status."

A 2019 Commonwealth Fund report identified 28 U.S. states as having at least some consumer protections relating to balance billing."{{Cite journal|url=https://www.commonwealthfund.org/sites/default/files/2019-08/To_the_Point_Hoadley_State_Balance-billing_Protections_073119_PDF.pdf|title=States Are Taking New Steps to Protect Consumers from Balance Billing, But Federal Action Is Necessary to Fill Gaps|journal=To the Point: Quick Takes on Health Care Policy and Practice|doi=10.26099/jfne-dp10|language=en|access-date=2019-11-20|last1=Hoadley|first1=Jack|last2=Lucia|first2=Kevin|last3=Kona|first3=Maanasa|year=2019|publisher=Commonwealth Fund}} This was an increase from 2017–2018, when a total of 25 states had at least some protections against surprise billing.{{Cite web|url=https://www.zelis.com/resource/senate-bill-and-state-balance-billing-laws-lean-on-providers/|title=Senate Bill and State Balance Billing Laws|last=Albright|first=Matthew|date=October 3, 2018|website=Zelis|language=en-US|url-status=live|archive-url=https://web.archive.org/web/20191002195448/https://www.zelis.com/resource/senate-bill-and-state-balance-billing-laws-lean-on-providers/ |archive-date=2019-10-02 |access-date=2019-10-02}} Only nine states had comprehensive consumer protections relating to balance billing at the end of 2018. That number rose to 13 states in 2019. Researchers consider a state to offer "comprehensive protections" against surprise bills if the state's law limits a consumer's "financial exposure to normal in-network cost sharing"; bars providers from balance billing; applies to both emergency department and non-emergency care in an in-network hospital; applies to both HMO and PPO enrollees; and creates a method for resolving payment disputes between providers and insurers (either through a specific payment standard or a dispute resolution process). The states with a comprehensive approach are California, Connecticut, Florida, Illinois, Maryland, New York,{{cite journal |last1=Lucia |first1=K |last2=Hoadley |first2=J |last3=Williams |first3=A |title=Balance Billing by Health Care Providers: Assessing Consumer Protections Across States. |journal=Issue Brief (Commonwealth Fund) |date=June 2017 |volume=16 |pages=1–10 |pmid=28613066}} Colorado, New Mexico, and Texas. A 2020 study found that reforms introduced by New York in 2014 successfully reduced out-of-network billing for emergency care by 88%.{{Cite journal|last1=Cooper|first1=Zack|last2=Scott Morton|first2=Fiona|last3=Shekita|first3=Nathan|date=2020-03-02|title=Surprise! Out-of-Network Billing for Emergency Care in the United States|journal=Journal of Political Economy|volume=128|issue=9|pages=3626–3677|doi=10.1086/708819|s2cid=216209047|issn=0022-3808|url=http://cep.lse.ac.uk/pubs/download/dp1524.pdf}} Similarly, after Texas enacted an anti-surprise billing law, the Texas Department of Insurance reported receiving up to 95% fewer surprise billing complaints.Ashley Lopez, [https://www.kut.org/post/far-fewer-texans-have-reported-surprise-medical-bills-new-law-went-effect Far Fewer Texans Have Reported Surprise Medical Bills Since New Law Went Into Effect], KUT (July 29, 2020).Jaie Avila, [https://news4sanantonio.com/news/trouble-shooters/state-says-complaints-down-95-percent-due-to-new-surprise-medical-bill-law State says complaints down 95 percent due to new surprise medical bill law], WOAI-TV (July 28, 2020).

In states with a law preventing or restricting surprise billing, commercially insured consumers who receive a surprise bill "may be able to obtain assistance from their state Department of Insurance, though state law protections may not cover all surprise billing situations, and may not cover people with insurance through their job."{{Cite web|url=https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/08/01/what-is-surprise-billing/|title=What is surprise billing?|last=Lee|first=Christen Linke Young, Matthew Fiedler, Loren Adler, and Sobin|date=2019-08-01|website=Brookings|language=en-US|access-date=2019-11-20}} Consumers who live in states that lack surprise billing protections sometimes negotiate with health care providers to write off a portion of the surprise bill, or for a repayment plan, and sometimes argue to their health insurer for the insurance company to pay a larger proportion of the bill.

The 2019 Commonwealth Fund report found that federal action was needed to comprehensively protect consumers from balance billing, given that (1) only federal law can comprehensively address patients from one state being treated by providers from another state and (2) federal law currently blocks states from enacting protections against surprise billing from air ambulance services. Congress gave the issue serious attention in 2018-2019{{Cite journal|url=https://www.healthaffairs.org/do/10.1377/forefront.20180924.442050/full/|title=Analyzing New Bipartisan Federal Legislation Limiting Surprise Medical Bills {{!}} Health Affairs|website=www.healthaffairs.org|year=2018 |language=en|doi=10.1377/forefront.20180924.442050|url-access=subscription}} with both the House and Senate passing substantive bills out of committee in the summer of 2019.{{Cite web|url=https://www.zelis.com/resource/unbalanced-differences-between-the-house-and-senate-surprise-billing-bills/|title=Unbalanced: Differences between the House & Senate SBB|last=Albright|first=Matthew|date=September 24, 2019|website=Zelis|language=en-US|url-status=live|archive-url=https://web.archive.org/web/20191002195448/https://www.zelis.com/resource/unbalanced-differences-between-the-house-and-senate-surprise-billing-bills/ |archive-date=2019-10-02 |access-date=2019-10-02}}

An American College of Emergency Physicians policy statement on balance billing noted that the Emergency Medical Treatment and Active Labor Act of 1986 requires patients presenting at an emergency department to be treated regardless of insurance coverage or ability to pay as a safety net, and argues that:{{blockquote|Unfortunately, the claims of physicians who provide emergency care for commercially insured services are often paid by health plans at rates that are substantially below the usual and customary value of these services. In the recent past, most plans based the allowed benefit for these services on the 70th or 80th percentile of usual and customary charges, but the database most often used for this purpose underrepresented these charges. ... In response to successful challenges to such flawed databases, some plans have established out-of-network benefit rates that are still substantially below usual and customary payments. Health plans know that emergency medical care must be provided for their enrollees no matter how poorly the plans pay for these services. The lack of a system to ensure fair benefit payments has allowed payers to underpay the fair value of emergency services, creating an imperative to preserve balance billing. Balance billing ensures the ability to provide patient care services where no enforced laws or regulations require health plans to pay appropriate benefits for emergency care claims at rates sufficient to maintain the financial feasibility of the nation's emergency care system.{{cite journal |title=Policy Statement: Balance Billing|journal=Annals of Emergency Medicine |date=September 2016 |volume=68 |issue=3 |pages=401–2 |doi=10.1016/j.annemergmed.2016.06.034 |pmid=27568434 }}}}

The "No Surprises Act" was signed into law as a part of the Consolidated Appropriations Act of 2021 on December 27, 2020.{{Cite web|url=https://www.congress.gov/bill/116th-congress/house-bill/3630|title=H.R.3630 - 116th Congress (2019-2020): No Surprises Act | Congress.gov | Library of Congress}}{{cite web | url=https://www.ama-assn.org/health-care-advocacy/access-care/implementation-no-surprises-act | title=Implementation of the No Surprises Act }}

In France, physicians who want to charge more than the government-negotiated set fees are considered to be in a separate "payment sector," which essentially means they are treated as self-employed. They can charge higher fees and receive reduced benefits. In 1987, about 27% of French physicians chose to balance the bill. The percentage is higher for specialists rather than generalists and doctors in urban rather than rural areas.{{cite book|last=Thompson|first=Lawrence H.|title=Health Care Spending Control: The Experiences of France, Germany & Japan|year=1992|publisher=United States General Accounting Office|isbn=978-0-7881-0574-6|pages=40}}

Balance billing is prohibited in Germany. Fee schedules are negotiated between sickness funds and physicians, and physicians are not permitted to charge more than the set amount.{{cite book|last=Thompson|first=Lawrence H.|title=Health Care Spending Control: The Experiences of France, Germany & Japan|year=1992|publisher=United States General Accounting Office|isbn=978-0-7881-0574-6|pages=41}}

Balance billing is prohibited in Japan, and extra fees are only allowed in a small number of circumstances, such as having a hospital bed with extra amenities.{{cite book|last=Ikegami|first=Naoki, John Creighton Campbell|title=Containing health care costs in Japan|year=1996|publisher=University of Michigan Press|pages=10|url=https://books.google.com/books?id=VyNYL_XAul0C&q=%22balance+billing%22+japan&pg=PA10|isbn=978-0-472-10538-0}}

Balance billing is prohibited in Taiwan, and extra fees have only been allowed recently and in rare defined circumstances. Today, patients in Taiwan are allowed to choose more expensive versions of some devices such as stents, implants or prosthetics, and to pay the difference in cost themselves.{{cite book|last=Okma|first=Kieke G. H., Luca Crivelli|title=Six Countries, Six Reform Models: The Healthcare Reform Experience of Israel, The Netherlands, New Zealand, Singapore, Switzerland and Taiwan: Healthcare Reforms "Under the Radar Screen"|year=2009|publisher=World Scientific Publishing Company|isbn=978-981-4261-58-6|pages=179–180}}

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