A customer holds a stack of past due bills. 

Deeming it too controversial for an election year, Mississippi lawmakers killed a bill that aimed to increase protections for patients against enormous out-of-pocket medical bills.

Currently, health care providers in Mississippi violate state law by “balance billing” patients. This happens when a provider bills a patient for the difference between the initial charges and the amount paid after insurance benefits are assigned.

But the existing law comes with little enforcement ability, Clarion Ledger discovered in June.

Following the newspaper report, House Insurance Chairman Rep. Gary Chism, R-Columbus, authored a bill to require the attorney general’s office to enforce the law and establish binding arbitration to resolve any balance billing disputes between providers and patients.

An overwhelming majority of Mississippians support anti-balance billing measures, according to a Mason-Dixon poll conducted on behalf of Mississippi Health Advocacy Program. Of the 625 Mississippi voters surveyed in January, 40 percent said they or a family member had received a surprise medical bill in the past. Eight-five percent said they support laws to protect patients against these bills by requiring providers and insurers to settle billing disputes themselves.

Chism said several lawmakers who are also medical professionals — nurses and nurse practitioners — approached him to voice opposition to his bill, which failed to advance on Tuesday’s deadline for bills to pass out of committee.

“They want to be able to get their money,” Chism said.

Though balance billing is prohibited by state law, the confusing nature of health care and insurance makes patients susceptible to predatory practices, health care advocates say. Plus, many people don’t know the anti-balance billing law exists or how it should be interpreted.

“The problem is twofold,” Roy Mitchell, director of Mississippi Health Advocacy Program said. “Many people don’t know exactly what balance billing is. Then once they’ve been balance billed, they don’t know where to go, how to get help.”

For example, if a provider charges a patient $1,000 for a procedure, but the insurance company has an “allowed amount” of $500 — that’s how much the insurer thinks the provider should be paid for the service. The patient may be required to pay a deductible or a 20 percent co-insurance of $100, leaving the insurer to pay $400.

Once the provider accepts that payment, state law says the bill should be settled, even though the provider has only received $500. If the provider tries to recoup the remaining $500, that would be a “balance bill” — a practice prohibited under a state law passed in 2013.

For an example of how much the provider price and allowed amount for a service can vary, University of Mississippi Medical Center charges $5,135 for a colonoscopy with biopsy but accepts a discounted rate of $177 from Blue Cross Blue Shield of Mississippi, according to documents from the Mississippi Insurance Department.

Large surprise bills usually arise when a patient unknowingly receives services from an out-of-network provider — an out-of-network radiologist inside an in-network hospital, for example — who has not agreed on discounts with an insurer. Insurers pay much less to out-of-network providers than providers in their network, leaving a larger bill for the patient in the event the provider sends a balance bill.

But Mississippi’s anti-balance billing doesn’t distinguish between types of networks, so as long as the provider accepts the insurance payment, “the payment shall be considered payment in full to the provider, who may not bill or collect from the insured any amount above that payment, other than the deductible, coinsurance, copayment or other charges for equipment or services requested by the insured that are noncovered benefits,” the law states.

Still, balance billing occurs, which is why Chism introduced an unsuccessful bill this session to add more teeth to Mississippi’s anti-balance billing statute.

Right now, patients can complain about balance bills to the Mississippi Insurance Department, which can try to mediate the bill, but the agency says it does not have the authority to force providers to comply with the law. The attorney general’s office has similarly said it cannot enforce the law and that a patient in this scenario would have to privately sue an uncooperative provider.

“They shouldn’t have to go spend money, hire an attorney to write a letter,” Chism told Mississippi Today before the 2019 session began. “Somebody ought to look at it and say, ‘This is a balance bill. You don’t owe it.'”

Chism’s legislation was double referred to the House Insurance and Judiciary A committees, which usually indicates “the leadership is not too keen on it,” Chism said. It died on Tuesday, the deadline for bills to come out of their respective committees.

While Chism said Speaker Philip Gunn, R-Clinton, hadn’t voiced any concerns over the proposal, Chism was approached by several lawmakers who are health care providers and oppose the bill. Chism said they oppose the existing anti-balance billing law, which flew under the radar when it passed during the 2013 session.

“They said that since it (the law) sort of snuck through, they didn’t want to deal with it in an election year,” Chism said.

He also indicated the law could be viewed as controversial to the health-care industry, one of the biggest lobbies at the Capitol.

Rep. Jarvis Dortch, D-Raymond

Rep. Jarvis Dortch, D-Raymond, also authored a bill to address balance billing, which would have required providers to better educate patients regarding balance billing and their options for mediation. It also died.

Chism called Dortch’s bill “much more radical than mine,” though the insurance chairman had considered replacing the language in Dortch’s bill with his legislation in order to pass it through the House Insurance Committee. Ultimately, “that would be sort of in the face of the leadership,” Chism said. “I decided it ain’t worth it.”

Mississippi had the highest percentage of people with past due medical debt — 37 percent — in the nation between 2012 and 2015, according to a 2017 Urban Institute report. Medical debt is the leading cause of bankruptcy in the United States.

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Anna Wolfe is a Pulitzer Prize-winning investigative reporter who covers inequity and corruption in government safety net programs, nonprofit service providers and institutions affecting the marginalized. She began reporting for Mississippi Today in 2018, after she approached the editor with the idea of starting a poverty beat, the first of its kind in the state. Wolfe has received national recognition for her years-long coverage of Mississippi’s welfare program, in which she exposed new details about how officials funneled tens of millions of federal public assistance funds away from needy families and instead to their friends, families and the pet projects of famous athletes. Since joining Mississippi Today, she has received several national honors including the Pulitzer Prize for Local Reporting, the Livingston Award, two Goldsmith Prizes for Investigative Reporting, the Collier Prize for State Government Accountability, the Sacred Cat Award, the Nellie Bly Award, the John Jay/Harry Frank Guggenheim Excellence in Criminal Justice Reporting Award, the Al Neuharth Innovation in Investigative Journalism Award, the Sidney Award, the National Press Foundation’s Poverty and Inequality Award and others. Previously, Wolfe worked for three years at Clarion Ledger, Mississippi’s statewide newspaper, where she covered city hall, health care, and wrote stories about hunger and medical billing, earning the Bill Minor Prize for Investigative Journalism two years in a row. Born and raised on the Puget Sound in Washington State, Wolfe moved to Mississippi in 2012 to attend Mississippi State University, where she currently serves on the Digital Journalism Advisory Board. She has lived in Jackson, Mississippi since graduating in 2014.