PA Physicians Explore Solutions to Balance/Surprise Billing Problem

The inaugural meeting of the Pennsylvania Medical Society’s (PAMED) Payer Advocacy Task Force was held via conference call in late March 2016. The first agenda item the Task Force is tackling is related to balance billing of patients by out-of-network (OON) practitioners.

The meeting was led by Chairwoman Karen Rizzo, MD, and physicians from a variety of specialties and geographic areas participated in the call. After receiving direction from the PAMED Board of Trustees, the Task Force is focused on root causes of physician balance billing to include the adequacy of health plan networks.

The Task Force reviewed a model network adequacy bill that was developed by the National Association of Insurance Commissioner (NAIC) and further refined by the American Medical Association (AMA). These refinements include deletions and additions to the original bill language. The Task Force reviewed the AMA changes to the bill and also made suggestions based on a very robust discussion among Task Force members.

PAMED staff will now look at specific terminology used in the AMA marked-up model bill such as definitions to determine if existing Pennsylvania statute or regulation definitions are preferable to the terms defined in the model bill. This will be the topic of the next Task Force meeting.

OON balance billing has been garnering a great deal of attention in Pennsylvania. PAMED testified at a hearing on balance billing last fall. Then, in January 2016, the Pennsylvania Insurance Department drafted proposed legislation to address the issue.

Following the release of the Insurance Department’s draft legislation, a common sentiment of the PAMED Board was that this issue is much more complex than just OON balance billing. Other underlying problems include inadequate networks, unfair contracting, and patient misunderstanding about the insurance products they have purchased. PAMED President Scott Shapiro, MD, addressed these concerns in this Feb. 29, 2016 letter to the Insurance Department. A second meeting between PAMED leadership and the PA Insurance Commissioner is being scheduled to further discuss this complex issue.

PAMED’s new Payer Advocacy Task Force and representatives from affected specialties have been tasked with examining issues connected with balance billing, with the goal of providing a reasonable solution for both Pennsylvania consumers and physicians alike.

PAMED believes it is important to get engaged and address these complexities, and welcomes member feedback on this issue. Share your comments by emailing Dennis Olmstead, PAMED’s senior advisor of health economics and policy, at