"The No. 1 reason to me is the consumers ... What we are attempting to do is get the consumers out of the middle of this," said Sen. Chuck Hufstetler, R-Rome, who is sponsoring SB 56.
The issue commonly arises in emergency rooms or in other instances when a patient with insurance coverage has unscheduled care. If a provider is out-of-network, the portion of the bill not covered by an insurer can be astronomical. And, sometimes weeks later, the patient gets a bill for the balance.
Michelle Kimball, president and CEO of Physicians for Fair Coverage, spoke in favor of the SB 56, noting that Georgia has the highest rate in the country for "narrow networks," where patients' choice of covered providers is restricted. A formula in the legislation would determine what the insurer must pay the provider, with the patient's cost limited to the in-network share.
"I didn't realize I could go to an in-network hospital and be treated by an out-of-network physician," Kimball said, speaking of her early days in the business. "Senate Bill 56 fairly pays our physicians and protects our patients."
The Medical Association of Georgia also supports the bill. Spokesman Derek Norton said it's a compromise from Hufstetler's bill last year, which passed the Senate but was blocked in the House. SB 56 uses an independent database of costs for services, melding the amount allowed by insurers with the typical charge by a provider.
"The problem is determining a fair payment standard ... This is a fair compromise," Norton said.
But insurance companies are continuing their pushback, with testimony from three industry groups objecting to the way the rates are calculated.
Alan Hayes, representing America's Health Insurance Plans, said the bill does address two concerns: It protects patients from getting balance bills from providers and it sets transparency rules so they are told up front — when possible — about out-of-network fees.
The reimbursement standard is the sticking point, he said.
"If you still have a component in (the calculation) that is whatever the provider wants it to be, we still have a problem," he said.
Hufstetler said he fully expects the legislation to change in some ways as it moves through the process. In the end, it would have to meet with approval in the House, which is reviewing a proposal that just requires patients to be notified of out-of-network care.
"It does have transparency but it doesn't change (balance-billing)... I think they will know exactly how they are getting hosed, but they will still be getting hosed," Hufstetler said.
SB 56 went through the Senate Insurance & Labor Committee instead of the Health & Human Services Committee where it was heard last year. That could send it on a path to a different House committee, instead of the H&HS committee where it did not get a hearing.