FACT SHEET

AN ACT RELATIVE TO ASSIGNMENT OF HEALTH INSURANCE BENEFITS

Sponsor: Representative William Galvin

This bill will require all health insurers to allow consumers to assign health insurance benefits directly to the health care provider. Health insurers would include commercial insurers, Blue Cross/Blue Shield, Health Maintenance Organizations and Preferred Provider Organizations. The bill also amends MGL 175O, the Consumer Protection statutes created by the Managed Care Reform Law, Chapter 141 of the Acts of 2000.

This bill will allow the common and long-standing practice of allowing patients to direct their insurance company to pay a physician directly to continue. Recently some insurers have begun ignoring a patient's assignment of benefits to a non-participating emergency physician. This has resulted in a situation whereby physicians who agree to participate will be paid by the insurer, in accordance with their fee schedule. Physicians who decline to participate will not be paid by the insurer; rather, the insurer will pay the member, in accordance with the physician's charge, and the member will be responsible for paying the physician. In one case, an insurer offered eligible physicians a one-time Network Participation Payment in exchange for execution of a three year agreement to participate in all BCBSMA products, including indemnity, PPO, HMO, at a reduced rate of reimbursement. This is one more example of unilateral and unfair physician contracting practices by health insurers.

The refusal by insurers to allow patients to assign benefits will have a chilling and distressing effect on the already overburdened emergency healthcare system in our state. Physicians who participate will be forced to accept lower fees in order to receive payment directly from the plan. Physicians who do not participate will incur increased administrative costs related to billing and collection of fees from patients. In either case, money and time better spent on providing care will be removed from the system, contributing to the continued difficulty of recruiting new physicians to Massachusetts as well as the continued exodus of physicians from the state. Emergency room overcrowding and diversion will worsen as patients lose their ability to otherwise access care.

Patients do not expect to be required to act as a conduit for reimbursement, yet insurers are increasingly thrusting patients squarely into the middle. Patients will have no way of knowing if the provider is a BCBSMA participating provider, nor should that be a factor, especially in an emergency situation. Moreover, consumers pay their insurance companies to cover their health care costs and handle the paperwork. Refusal to allow assignment of benefits will result in both confusion and hardship among consumers.

The practice of ignoring a patients choice to assign benefits creates a barrier to care and, therefore, circumvents the protections afforded by Chapter 141 – especially regarding access to emergency services. If health plans refuse to reimburse providers directly for emergency services obtained by insured patients, even after patients have assigned their benefits to providers at the time of treatment (as is common practice), patients may feel inhibited from seeking emergency care when they believe they are experiencing a true emergency medical condition. Especially if it involves large health plan in the state; this practice could likely result in placing patients in a similar position as they were in prior to the enactment of Chapter 141, that of being deterred from seeking emergency services and being administratively and financially burdened in order to obtain reimbursement for emergency services.

In addition, Chapter 141 reconciled Massachusetts law with EMTALA, the federal law regulating emergency services, which requires that everyone who presents to an emergency department be examined and treated no matter their ability to pay, insured or not insured. Emergency physicians provide medical care when others cannot or will not, and the Managed Care Reform Act assured patients that they will receive coverage from their health plan for this care. It stands to reason that emergency physicians should be assured payment as well.

In summary, this bill will prevent an already stressed health care system from worsening. It will prevent health insurers from circumventing the protections of Chapter 141 and attempting to coerce physicians to become participating providers by placing patients squarely in the middle of the reimbursement process and compromises patients' access to care.