UCSF Admits To Balance-Billing Patients
A medical group affiliated with University of California San Francisco and the Bay Area's largest safety net provider has admitted it illegally balance-billed emergency room patients for more than five years.
According to a settlement reached between the leadership of the San Francisco General Hospital Medical Group and the Department of Managed Health Care, the group had been balance billing members of a Blue Shield of California PPO between January 2009 and March of 2014, apparently assuming the plan was not regulated by the DMHC and the Knox-Keene Health Act that governs managed care plans in California.
The SFGH Medical group is operated by UCSF physicians and is affiliated with San Francisco General Hospital, although it is an entirely separate entity. San Francisco General Hospital is named on the DMHC website as part of the action, but not in the official documentation.
According to DMHC spokesperson Rodger Butler, 339 patients were balance- billed over the five-year period and a total of $105,000 was collected. The agency became aware of the practice as the result of consumer complaints. The settlement agreement suggested that patients were referred to the medical group's collection agency, although data on how many was unavailable.
A 2009 California Supreme Court case, Prospect Medical Group, Inc. v. Northridge Emergency Medical Group, bars the balance billing of any enrollee in a plan regulated by the Knox-Keene law for emergency room services. The Supreme Court handed down its decision on Jan. 8, 2009 and effectively barred balance billing for emergency room patients moving forward.
Between 2006 and 2009, patients in California were balance billed as much as $528 million, according to data from the California Association of Health Plans.
Despite the Supreme Court decision, there have been a couple of high-profile cases on balance billing in the intervening years. The largest involved Ontario-based hospital operator Prime Healthcare, which agreed in 2010 to stop balance billing enrollees in some Kaiser Foundation Health plans, and Jeannette Y. Martello, M.D., a South Pasadena plastic surgeon against whom the DMHC won a $562,000 judgment in 2013 for her balance- billing of patients she treated in Los Angeles-area emergency rooms.
As part of its agreement with the DMHC, the SFGH Medical Group agreed not only to stop balance billing enrollees of health plans regulated by the agency, but to also refund sums collected after Jan. 9, 2009, along with annual interest payments of 10%. The medical group also ordered its collection agency to stop dunning patients, and agreed that if the DMHC or any other regulatory agency contacts its staff, it is to respond in a timely fashion.
“(The medical group) worked diligently and collaboratively with the Department of Managed Health Care in getting this matter corrected,” Sue Carlisle, M.D., a UCSF vice dean who oversees the SFGH Medical Group, in an email. “We have taken all corrective actions required, provided all progress reports to DMHC, and continue to monitor compliance.”
A Blue Shield spokesperson declined to immediately comment.
The settlement regarding balance billing is the second secured by the DMHC in recent weeks.
It also secured a settlement from North Coast Pathology Medical Group in Oceanside. The five-physician North Coast Pathology provides pathology and laboratory services to several hospitals in the San Diego area but primarily Tri-City Medical Center.
North Coast had also been balance-billing patients since 2009, primarily those enrolled in health plans operated by Anthem Blue Cross of California, Blue Shield of California, Aetna and Health Net. Butler said the amount and number of patients balance-billed had not yet been determined.
As part of its settlement, North Coast agreed to repay patients the sums collected plus interest of 7% a year.
A spokesperson for North Coast declined to comment on the matter.
