'Surprise' billing risk is low for CalPERS members
June 4, 2019
A May 31 Sacramento Bee article states that 250,000 CalPERS PPO members are at risk of "surprise" medical bills known as "balance billing." The article's headline and first paragraph wildly overstate the issue and lack any context about how our members receive medical care. It has raised some questions that need clarifying and further explanation.
As the story says, balance billing occurs when patients receive treatment from physicians or at medical facilities that are not part of their insurance plan's network. "For the most part," the story says, "the bills can be avoided by getting treatment from in-network doctors and hospitals."
That's a crucial point and one that needs to be highlighted: In 2017, 96.5 percent of CalPERS PPO members seeking medical care obtained that care from in-network providers. That means they were in absolutely no danger of receiving "surprise" balance bills because patients receive these bills only when they seek treatment outside the plan's network.
Sometimes patients have no choice but to seek out-of-network care. In 2017, about 1.3 percent of care CalPERS PPO members received was emergency room care from non-participating providers. In these cases, CalPERS pays at a higher in-network percentage based on allowed amounts. Most providers accept these payments.
It's important that our members be able to choose care from as large a medical network as possible. Anthem — which administers our PPO plans — has the broadest hospital and provider network in all of California, with over 82,000 network providers and hundreds of hospitals across the state's 58 counties.
We monitor all member care and work aggressively to mitigate issues that might put patients at risk of the kind of "surprise" medical costs the Bee story calls out. Working with Anthem, we have been overwhelmingly successful in protecting our members from egregious balance billing practices.