After a hospital visit — whether it’s a surgery or an emergency room trip — it’s not uncommon to wind up with a couple bills, perhaps even from providers whose names you don’t recognize.

The doctors who treat patients in the emergency department at St. Charles Bend, for example, work for a group called Central Oregon Emergency Physicians.

The anesthesia is provided by the Bend Anesthesiology Group.

Other providers are sometimes involved, too. Each of those providers has its own list of insurers it contracts with, and those lists don’t always line up with that of St. Charles Health System.

That means even if you were diligent enough to make sure St. Charles was within your insurance carrier’s network and subject to your policy’s discounted rates, those other providers might not be. In emergency situations, insurers sometimes agree to pay out-of-network providers at in-network rates, so long as they’re seeing patients at an in-network hospital.

“Even if you know that this is an issue and try to do the right thing, it’s not possible with the way the rules work today,” Jesse Ellis O’Brien, policy director for the consumer advocacy group OSPIRG and OSPIRG Foundation, told state lawmakers at a hearing last week.

Broadly speaking, the term balance billing refers to a medical provider sending a patient a bill for whatever that patient’s insurer did not cover.

Oregon lawmakers are considering legislation that would prohibit out-of-network providers from billing patients for services provided at an in-network facility, such as a hospital. The most common example is when a hospital is in-network, but the doctors working there are not.

The measure would also establish a system for paying out-of-network providers that insurers would have to adhere to.

A public hearing on the subject last week illustrated just how complicated a seemingly straightforward idea like this one will be to move forward. The issue seemed to pit insurance companies, who support the measure, and medical groups, who oppose the measure, against one another. While insurers argue balance billing is a huge problem, doctors downplayed it and said it’s driven largely by insurance carriers not paying them enough.

While everyone at last week’s hearing agreed balance billing should end, at issue is how much out-of-network providers should be paid for their services.

One idea has been to pay them a percentage of Medicare rates. Another has been to use a national database provided by a nonprofit called Fair Health, which aggregates reimbursement data from a number of private insurers that can be used to determine reimbursement rates in accordance with a state’s regulations. New York state used Fair Health in its own efforts to address surprise billing.

“The issue is not whether we ought to be doing it but how much they ought to be paid,” Rep. Mitch Greenlick, a Democrat from Portland who chairs the House Health Care Committee, remarked at last week’s hearing. “That seems to be the biggest issue.”

Docs vs. insurers

Groups representing both emergency physicians and anesthesiologists in Oregon oppose the bill, which was written by the state’s Department of Consumer and Business Services, arguing it will devastate their bottom lines.

Dr. Dan Bissell, an emergency physician and president and CEO of Northwest Acute Care Specialists in Portland, told lawmakers at the hearing that a proposed amendment to the bill that suggests reimbursing providers at 175 percent of Medicare rates would cut reimbursement to providers by more than half in some cases.

“In that scenario, then providers would suddenly face a substantial pay cut and likely would face difficulty maintaining the providers we have and recruiting new ones,” he said. “ER docs are in high demand. They would likely go to other parts of the country.”

Insurance carriers — including Providence Health Plan and Cambia Health Solutions, the parent company of Regence BlueCross BlueShield of Oregon and BridgeSpan Health — support the measure.

Tom Holt, Cambia’s director of public affairs and policy, told lawmakers balance billing is the “number one pain point” among his customers. He said paying out-of-network providers a percentage of Medicare rates would be a simple solution.

The measure also proposes establishing a dispute resolution process regarding payment to out-of-network providers.

O’Brien told lawmakers he’s concerned the bill doesn’t include an enforcement plan in the event providers continue to balance bill once it’s passed.

Bend group a mystery

Insurance carriers typically reimburse Central Oregon Emergency Physicians at their discounted, in-network rates whether they have a contract with the group so long as St. Charles is in network, said Dr. Gillian Salton, an emergency physician who works for Central Oregon Emergency Physicians and sees patients at St. Charles Bend.

Salton said her office still sends patients bills to collect whatever deductible or co-payment their insurer requires them to pay to see in-network providers.

“It’s not that patients won’t receive a bill, it’s that they won’t receive a bill for more than they and their insurer agreed to pay,” she said.

It would be difficult for patients to learn which carriers Central Oregon Emergency Physicians contracts with. It doesn’t have a website or a local phone number. Bend Anesthesiology Group, by contrast, maintains prominently on its website a list of insurance carriers it contracts with.

Salton could not say which insurance carriers Central Oregon Emergency Physicians contracts with. Dr. Mark Sampson, a physician and one of the group’s directors, could not be reached for comment.

In 2014, Sampson told The Bulletin the group did not contract with UnitedHealthcare, Providence Health Plan, Aetna, LifeWise, HealthNet and Cigna, all carriers that St. Charles contracts with. It’s unclear whether that’s still the case.

— Reporter: 541-383-0304,

tbannow@bendbulletin.com