4 4 [8 8 O p
. A tt ’y HEALTH I NSURANCE

– E FFE CT OF 2 0 01 A MEN DME NT OF H MO L AW ON L AW ’ S B ALANCE B I L L I NG P ROHI B I T I ON A ND A B I L I T Y OF H MO M E MBE RS T O E NT E R I NT O P RI V ATE C ONT RACTS W I T H P ROVI DE RS

M ar ch 13, 2003

The H onor abl e John P. D onoghue Mar yland H ous e of D el egat es T hr ee y ear s ago, aty ourr eques t , t hi s O ffi ce i s s ued an opi ni on th a t d isc u ss e d th e c irc u m sta n c e s u n d e r w h ich a m e m b e r o f a h e a lth m ai nt en a n c e o r g a n i z a t i on ( “H M O ”) m ayent eri nt o a pr i vat e contr act w i t h a hea l t h car e pr ovi derhavi ng no r el at i o n t o t he H M O and wh e t h e rt h e s t a tu t o r yp r o h i b i t i o n a g a i n s tb a l a n c e b i l l i n g o f HM O m ember s w oul d appl y t o t hatcontr act

. Y ou now as k w hethera 2001 amendm entof t he St at e H M O l aw change s t he ans w er s gi ven i n t hat opi ni on. I n ouropi ni on, t he 2001 amendm entof t he H M O l aw w as i nt ended t o i ncr eas e the compens at i on of t r auma p h y sic i ans w hen t h ey tr ea tpat i ent s w ho happen t o be H M O m ember s
. I tw as not in ten d e d to a f

f e c t th e a b ili tyo f H M O m e m b e rs to e n ter in to p riv a te c o n tra c ts w ith o th e r h e a lth c a re p ro v id e rs. N o r w a s it in ten d e d to a f f e c tt h e r e s t r i c t i o n s o n d i r e c tb i l l i n g o rb a l a n c e b i l l i n g o f H MO m ember s by ot her heal t h car e provi der s
. H ow ever , beca us e the 2001 l e g i s l a t i o n c o u l d b e r e a d l i t e r a l l yt o l i mi tt h e a b i l i t yo f HM O m ember s t o ent eri nt o pr i vat e contr act s conce r ni ng s er vi ces i ncl uded i n t he H M O benef

i tpacka ge, t he G ener al A ssem bl ys houl d cl ar i fy i t s i n t e n twi t h a n a p p r o p r i a t e a me n d me n to f t h e HM O l a w.

I Backg r ound T o ans w ery ourques t i on, w e m us t pl ace i tw i t hi n t he hi s t or i cal c o n t e x to f

t h e b a l a n c e b i l l i n g p r o h i b i t i o n i n t h e M a r y l a n d HM OG en. 44] 45

The Mar yland Health Maintenanc e Org anization Act is codified 1 at Annotated Codeof Maryland, Health-General Ar ticle, §19-701 et seq. In this opini on, the terms “out- of-n etwo rk provider,” “ non- 2 participating provider,” and “non- contra ctingprovi d er” areused sy n o ny mo u s ly to me ana

h e a lt hc ar e p r o v id e r

wh o is n o t u

n d e r contra ct with the patient’s HMO to provideservice s to the HMO’s member s. l aw
. T hathi s t or yw as chr oni cl ed i n s om e det ai l i n a 1998 opi ni on 1 of t hi s offi ce. 83 O

pi ni ons of

the At t or ney G ener al1 2 8 (1 9 9 8 ) . A l at er opi ni on i s s ued at y ourr eques tdi s cus s ed the r el at i ons hi p of t he b a lan c e b ill in g p ro h ib iti o n to th e a b ili tyo f a h e a lth c a re p ro v id e r to bi l l an H M O m ember undera pr i vat e contr actbetw een the pat i ent and provi der

. 85 O

pi ni ons of the At t or ney G ener al3 3 0 ( 2 0 0 0 )

. We fi rs tsum m ari ze th a this t oryand t he co nclusi on s r eache d in t ho se o p in io n s
. A . P roh ibiti on A ga in st B alance B il

lin g o f H M O Mem bers S in c e 1 9 8 8 , the M a ry lan d H M O law h a s re q u ire d c o n tra c ts b e tw e e n H M O s a n d h e a lth se rv ice p ro v id e rs to c o n ta in a “ h o ld h a r m l e s s ” c l a u s e t h a tb a r s t h e p r o v i d e r f r o m c h a r g i n g H MO m ember s fors er vi ces pr ovi ded u n dert he contr actot hert han copaym ent s , ot her char ges per m i t t ed by t he H M O pl an, and cha r ges for s e rv ic e s n o t c o v e re d b yth e H M O p la n
. See A nnot at ed C ode of M ary l and , H eal t h-G eneral A rt i cl e (“H G ”), §1 9-710 (i ). B yi t s t erm s, th is b a n a g a in st d ire c t b ill in g o f H M O m e m b e rs a p p lies o n lyto p ro v id e rs w h o a re u n d e r c o n tr a c t w ith th e H M O

. I n 1 9 8 9 , t h i s c o n c e p twas e x t e n d e d t o n o n - c o n t r act i ng providers w hen t he L egis l ature e nacted t he p rohi bit i on against balance bil l i ng of H M O m em bers. See 83 O pi ni ons of the At t or ney 2 G ener al1 2 8 , 1 3 0 -3 3

. A s a re su lt, a n H M O m e m b e r i s n o t li a b le to any heal t h car e prov iderfora “c over ed s er vi ce” pr ovi ded t o t he m ember

. H G §19- 710( p) ( 1)

. H ow ever , t he H M O m ember r emai ns l i abl e forco- paym ent s and co- i ns ur ance as pr ovi ded i n t he pl an, as w el l as fors er vi ces notcover ed byt he H M O pl an
. H G §19- 7 1 0 (p )( 3 ). T he “h old harm l ess” r equ i rem ent and t he p rohi bit io n against bal ance bi l l ing t ogether“expl i ci t l ypr ovi de thats ubs cr i ber s or m ember s ow e n o debtt o any h ea lth ca re p rov ider ( i

. e. , an yd o ctor, hos pi t al , et c. ) foranycover ed s ervices. ” R iem e r v . C o lu m b ia Medi cal P l an, I nc. , 358 M d. 222, 244, 747 A

. 2d 677 ( 2000)4 6 [8 8 O p
. A tt ’y

Th e rule s a g a ins t balanc e bil lin gdo no t a pp ly to a n o ut- of -s tate 3 provider who is not under contra ct with a Mar yland HMO an d d oes not oth e rw isehavethe mi nim um c onta c ts w ithMary land that perm it application of Ma

ryland law. See83 Opinions of the Attorney Ge n eral 128, 135-40. ( e mp h a s i s a d d e d )

. T h u s , p r o v i d e r s , wh e t h e rp a r to f t h e HM O netw or k or not , ar e prohi bi t ed fr om di r ectbi l l i ng orbal ance bi l l i ng H M O m e m b e rs f

o r “ c o v e re d s e rv ic e s .” 3
T he i nabil it yt o bi l l H M O m ember s di r ect l yfor“cove r ed s er vi ces ” appa r ent l ydi s cour aged non- p ar t i ci pat i ng pr ovi der s fr om tr ea ti n g H M O m em b ers. See 83 O pi ni ons of

the At t or ney G ener al 1 2 8 , 1 3 4

. T h e Ge n e r a l As s e mb l y r e s p o n d e d i n 1 9 9 1 b ye n a c t i n g HG §19- 710. 1. I n l i eu of b il li n g H M O m ember s di r ect l yfors er vi ces c o ve r e d b ya n HM O p l a n , a n o u t

- o f

- n e t wo r k p r o v i d e rb e c a me e n t i t l e d t o r e i mb u r s e me ntf r o m t h e HM O wi t h i n a s p e c i f i e d t i me p e r i o d a ta mo r e f

a v o r a b l e r a t e t h a n t h e HM O c o n t r a c tr a t e
. HG § 1 9 -7 1 0 .1 (b ). T h e H M O c o u ld in tu rn se e k re im b u rse m e n t f ro m its m ember i f i tdet er m i ned thatanyamount pai d t o t he provi derw as the re sp o n sibil ityo f th e m em b er. H G § 1 9 -71 0

. 1 (c)(1). T he new s t atut e al s o defi ned “c over ed s er vi ce” : “C over ed s er vi ce” m eans a hea l t h car e s er vi ce in c lu d e d in th e b e n e f

it p a c k a g e o f

th e h e a lth m ai nt enanc e or gani zat i on and r ender ed t o an enr ol l ee of

t he h ea lt h m ai nt enanc e o rga n izati o n b ya h ea lth ca re p rov ider, i ncl udi ng a phy s i ci an orhos pi t al , notunder w ri tt en contr actw i t h t he hea l t h m ai nt enanc e or gani zat i on: ( i ) Pur s uantt o a verbal or w r i t t en r efe r r al by t he enr ol l ee’ s heal th m ainten ance or gani zat i on orbya p rovi derunderw r i t t en c o n tra c t w ith th e e n r o ll e e ’ s h e a lth m ai nt enanc e or gani zat i on; or ( i i ) T hathas been pr eauthor i zed or o th e rw is e a p p ro v e d e ith e r v e rb a llyo r in w r i t i ng byt h e enr ol l ee’ s heal t h m ai nt enanc e or gani zat i on ora pr ovi der u n derw r i t t enG en. 44] 47

In a deve lopment not directly related to your question, the 4 L eg is latu r e c r e ate d

an o th e r v e h ic lef

o r c o mp e n s ati n go ut- o f

- n e tw o rk providers f

or ser vices provide d to plan members, which incorporated the possibili ty

of bala nce billingof pl an members. L eg islation passed in 1995 require d employers who offe r health care bene fits through an HMO pla n to also offe r a “point-of-ser vice”option. SeeChap t er 6 0 5 , L aws of Maryland 1995, codified at HG §19-710.2. A point-of-ser vice plan allows a subscriber to re ceivecovered tre atment by an out- of-ne twork provider without a prior re fer

ral or a uthorization by

the plan, al though the subscriber

may be liable f

or additi onal fees, i ncluding balanc e bil ling by the out-of- network provider. See83 Opinions of the Attorney Gene ral

. 128, 133-35.

c o n tra c t w ith th e enrol l ee’s hea lth m ai nt enanc e or gani zat i on. H G §19- 710. 1( a) ( 3) ( 2000 R ep l. V ol

. )

. W hi l e thi s defi ni t i on sp e c if ica llyp e rta in e d to H G § 1 9

- 7 1 0 .1 , tha t sta tu te w a s c lea rly des i gned t o corr el at e w i t h t he pr ohi bi t i on agai ns tbal ance bi l l i ng for cover ed servi ces i n H G §19- 710( p)

. T he 1998 O pi ni on s um m ar i zed this relati o n sh ip: “ T h u s, as o f 1 9 9 1 , n o n -co n tr ac ti n g p rov iders w ere e n tit led to b e p a id p r o m p tl y a n d a t a h ig h e r ra te b u t w e re still p r o h i b i t e d f

r o m b a l a n c e b i l l i n g o ro t h e r w i s e c h a r g i n g H MO m e m b e rs f

o r c o v e re d se rv ice s. A ll p ro v id e rs, of c o u rse , c o u ld still di r ect l y bi l l H M O m ember s for non- cover ed servi ces
. ” 83 O pi ni ons of the At t or ney G ener al128, 133. 4 Th e 1 9 9 1 a me n d me n tp r o v i d e d a s t a tu t o r yf o r mul a f o rt he compensa t i on t hat a pr ovi der w as t o r ece i ve fr om t he H M O i n l i eu of bi l l i ng t he pat i ent

. I n i t s or i gi nal ver s i on, H G §19- 710. 1 di r ect ed th a t h o sp itals w e re to b e p a id a t th e ra te a p p r o v e d b yth e H e a lth Ser vi ces C os tR ev i ew C om m i s s i on ( “H SC R C ”) , and thatot her p rov iders w ere to b e p aid a t th e ra te bill ed o r at th e p rov ider’s “us ual , cus t om ary , and r eas onabl e” ( “U C R ”) r at e. H G §19- 710. 1( b) (1 9 9 6 R e p l. V o l.)

. N i ne y ear s l at er, the L egi s l atur e al t er ed the met hod for d eterm ining the c o m p en sati o n o f n o n -h o s p it al pro v iders. U n d er a 2000 amendm ent , an H M O w as t o paya non- hos pi t al pr ovi der125% of t he r at e t hatt he H M O pai d a compar abl e contr act i ng pr ovi derfor the same se r vi ce ort he ac tual r at e i thad hi s t or i cal l ypai d t o noncontr act i ng pr ovi der s , w hi cheve r w as gr eat er
. C hapt er275, L aw s of M ary l and 2000. A y ear l at er , another amendm entadded a di ffe r ent m et hodo l og yfo rde t e r mi ni ng pa y mentof t r a uma c a r e pr ov i de rs
.4 8 [8 8 O p
. A tt ’y C h ap ter 42 3 , L aw s o f M ary land 2 0 0 1

. Y o u r qu esti o n relates to p art of t hatamendm entand i s di s cus s ed i n gr eat erdet ai l i n Par t s I

. C

. and I I of t hi s opi ni on. B . P r i vate Contr act s B etw een H

M O Mem bers and O ut-ofN etw ork P rovi ders I n 2000, a quest i on ar os e as t o t he ci r cumst ance s underw hi ch an out

- o f-n etw or k pr ovi dercoul d char ge an H M O m ember t he p r o v i d e r ’ s n o r ma l f

e e f o rs e r v i c e s o f

a t yp e i n c l u d e d i n t h e HM O pl an. A s not ed above , w i t h r es pectt o a “c overe d serv i ce, ” the H M O l aw cl ear l y s et t he t er m s of t he pr ovi der ’ s compensa t i on fr om t he H M O and barr ed t he pr ovi derfr om di r ect l ychar gi ng orbal ance b ill in g th e H M O m e m b e r. In a ss e ss in g th e e x ten t to w h ich a n o u tof- netw or k pr ovi dercoul d di r ect l y contr act w i t h an H M O m ember t o pay t he provi der ’ s nor m al fee , w e t hus l ooked t o t he defi ni t i on of “cove r ed s er vi ce” i n H G §19- 710. 1( a) ( 3)

. W e conc l uded:

T h e H MO l a w d o e s n o tp r o h i b i ta n H MO m ember fr om ent er i ng i nt o a pri vat e contr act w i t h a hea l t h car e pr ovi derout s i de of the cont exto f t he H M O

. . . . T he bal ance bi l l i ng p ro h ib iti o n in th e S tate H M O law a p p lies o n ly to th e p ro v is io n o f

“ c o v e re d s e rv ic e s .” 85 O pi ni ons of

the At t or ney G ener al 3 3 0 , 3 3 4 -3 5 . W e re a so n e d th a t, e v e n if a p a rticu lar se rv ice w a s in c lu d e d in th e H M O ’s b e n e f it packa ge, i tw oul d n o tfi tt he def i ni t i on of cove r ed s er vi ce i f t he m ember w as notr efe r r ed to the p r ovi derbyt he H M O and i f t he H M O di d notaut hor i ze oro therw ise appr ove the pr ovi s i on of t he s e rv ic e to its m e m b e r. Id

. at 335. I n t hos e ci r cumst an ce s, n ei t her t he bal ance bi l l i ng pr ohi bi t i on of H G §19- 710( p) nort he pr ovi der compensa t i on pr ovi s i ons of H G §19- 710. 1 w oul d per t ai n. W e ca uti o n ed t hatt he pat i ent ’ s i nt entt o acc es s t he pr ovi der out s i de the H M O pl an and the pat ie nt ’ s know l edge of t he cons equenc es of t hatdeci s i on s houl d b e cl ear l ydocument ed att he t i m e a pr i vat e contr actw as for m ed. 85 O pi ni o n s o

f the A t t or ney G en eral3 3 0 , 3 3 5

. “ Th e wr i t t e n d o c u me n t

. . . s h o u l d c l e a r l ya nd conci s el yi nfor m t he mem berof t he fi nanci al consequence s of e n t e r i n g i n t o a p r i v a t e c o n t r a c to u t s i d e t h e c o n t e x to f t h e HM O – i

. e. , that the m em b er w il l be s o lel yresp o n s ible fo r t h e p rov ider’s charg es , t hatt he H M O w i l l notpayt he pr ovi der , t hatt he pr ovi der w ill n o t ac ce p t pay m en t from the H M O , an d that the m em b er’s obl i gat i on t o payH M O pr emi um s w i l l notbe af fec t ed. ” I

d.G en. 44] 49 C . A m endm ent

of D ef ini ti on of

“Cover ed Ser vi ce” A ft e rt h e 2 0 0 0 o p i n i o n was i s s u e d , t h e Le g i s l a tu r e a me nded th e d e f in itio n o f

“ c o v e re d s e rv ic e ” in H G § 1 9 -7 1 0 .1

. See C hapt er 4 2 3 , L a ws o f

M a r y l a n d 2 0 0 1

. T h a t l e g i s l a t i o n e l i mi n a t e d t h e t wo su b o rd in a te c lau se s tha t c o n d iti o n a “ c o v e re d se rv ice ” o n a re f e rra l, pr e- author i zat i on, orot herfor m of appr oval by t he H M O

. T hus , t he defini t i on no w reads:

“C over ed s er vi ce” m eans a hea l t h car e s er vi ce in c lu d e d in th e b e n e f

it p a c k a g e o f

th e h e a lth m ai nt enanc e or gani zat i on and r ender ed t o an enr ol l ee of t he heal th m ai nt enanc e o rga n izati o n b ya h ea lth ca re p rov ider, i ncl udi ng a phy s i ci an orhos pi t al , notunder w r i t t en cont r act w i t h t he heal t h m ai nt enanc e or gani zat i on. H G §19- 710. 1( a) ( 3) ( 2002 Supp. )

. A s not ed above , t hi s defi ni t i on esta b lis h e s the u n iverse o f se rvice s fo r w h ich a n o u t- o f-n etw o rk pr ovi deris en ti tl ed to the statu tori ly -de fin ed reim b u rsem en t from the H M O a n d , c o n c o m ita n tly, is b a rr e d f ro m c h a rg in g th e p a tie n t. Y ou have as ked w hether t hi s amendm entaff ect s t he abi l i t yof an H M O m ember and an out

- of- netw o rk p rov ide rt o ent eri nt o a pr i vat e contr actt hati s out s i d e the cont extof t he H M O and not s u b j e c tt o t h e b a l a n c e b i l l i n g p r o h i b i t i o n o f t h e HM O l a w.

II A n a ly sis I tm i ghtbe ar gued t hat , w i t h t he el i m i nat i on of anyr efe r ence t o a r efe r r al orappr oval byt he H M O , a “c o v ere d s er vi ce” i s now sim p lya n yse rv ice in c lu d e d in th e H M O b e n e f it p a c k a g e th a t an o u tof- netw or k pr ovi derpr ovi des foran H M O m ember , r egar dl es s of wh e t h e rt h e HM O a u t h o r i z e d p e r f o r ma n c e o f t h e s e r v i c e
. As expl ai ned above , H G §19- 710. 1 w oul d s ett he am ountof compensa t i on fort hats er vi ce, and the out

- of- netw or k pr ovi der w oul d be barr ed fro m bal ance bi l l i ng t he mem berfort hats er vi ce. U n d er this i n terpretati o n , an H M O m em b er a n d an o u t- o f -n etw o rk pr o v ide rcoul d notent eri nt o a pr i vat e contr actt hatpr ovi ded for gr eat ercom p en s at i on t o t he pr ovi deri f t he s er vi ce w as par tof t he H M O ’ s benef

i tpacka ge.5 0 [8 8 O p
. A tt ’y O n th e o th e r h a n d , it se e m s u n lik e lyth a t th e L e g isla tu re w o u ld d ra m a tica llyre stric t th e f re e d o m o f H M O m e m b e rs to e n ter in to p r i v a t e c o n t r a c t s i n s u c h a n i n d i r e c ta n d c i r c u i t o u s f a s hi on. M or eover , t hati nt erpr et at i on w oul d appea rt o under m i ne the i ncent i ve fora pr ovi dert o contr actdi r ect l yw i t h an H M O s i nce a ny p rov ider, w h ethe r au tho ri ze d b ythe H M O o r no t, co u ld p erf o rm s er vi ces pr ovi ded i n t he H M O benef i tpacka ge foratl eas t125% of t he c o n t r a c tr a t e
. W h e n a l i t e r a l i n t e rp r e t a t i o n o f a n a me ndm ent ap p ea rs t o y iel d an il log ical resu lt , th e p ri n ciples o f statuto ry c o n stru c tio n in stru c t u s to c o n sid e r th e leg isla tiv e h isto ryo f th e b ill and “other m at er i al t hat fai r l y bear s on t he fundament al i s s ue of l egi s l at i ve purpos e orgoal

. ” Kaczorow ski v. C i t y of Ba l t i m ore , 309 M d . 5 0 5 , 5 1 5 , 5 2 5 A .2 d 6 2 8 (1 9 8 7 ); s ee al s o C ons ol i dat ed C ons tr uct i on Ser vi ces , I nc. v. Si m

ps on , 372 M d. 434, 4 5 6

- 57, 813 A

. 2d 2 6 0 ( 2 0 0 2 )

. Th a ta n a l y s i s r e v e a l s t h a ta me c h a n i c a l l yl i t e r al i nt erpr et at i on of t he amendm ent w oul d be atodds w i t h t he l egi s l at i ve hi s t or y of t he bal ance bi l l i ng pr ohi bi t i on and the evi dent p u rp o s e o f

th e 2 0 0 1 le g is la tio n
. Th e 2 0 0 1 l e g i s l a t i on wa s f o c u s e d e x c l u s i v e l yo n t r a u ma phy s i ci ans
. T he s pons or of t he bi l l t es t i fi ed t hat itw as “ ta r get ed s peci fi cal l yt o phy s i ci ans t hatpr ovi de tr aum a ca re. ” Tape of t e s t i mon yo f

Se n a t o rJ o h n As t l e b e f o r e t h e Se n a t e Fi nance C om m i t t ee on Sena t e B i l l 728 ( M ar ch 7, 2001)

. A s out l i ned above , begi nni ng i n 1991, t he s t atut e s peci fi ed a m ethod fordet er m i ni ng t he amount t hatan H M O w as t o paynon- contr act i n g pr ovi der s for cover ed s er vi ces
. B etw een 1991 a nd 2000, r e i mbu r s e me ntof out

- ofnetw or k phy s i ci ans w as key ed t o t he U C R r at e. A s a r es ul tof t he 2000 l egi s l at i on, a non- contr act i ng phy s i ci an w as ent i t l ed t o 125% of t he r at e pai d t o a contr act i ng pr ovi der , or , i f gr eat er , t he r at e that th e H M O h a d h isto ric a llyp a id to n o n - c o n tra c tin g p ro v id e rs. T h is new m ethodol ogyw as appar ent l ydeemed i nadequa t e for compensa t i on of t r auma phy s i ci ans
. T he s pons ori ndi cat ed thatt he b ill w a s in te n d e d to “ re c tif y ” th a t s itu a tio n
. I

d. Ot h e r a d v o c a t e s o f t h e 2 0 0 1 l e g i s l a t i o n t e s t i f i e d t h a tt r a uma cent er s t r eat ed a di s pr opor t i onat e s har e of uni ns ur ed and u n d e ri n s u re d p a t i e n ts

. See, e. g. , T es t i m onyof Thom as M

. Scal ea, Phy s i ci an- i n- C hi ef, R A dams C ow l eyShock T r auma Cent er( M ar ch 7, 2 0 0 1 ). W hi l e hos pi t al s ar e compens at ed fort hos e s er vi ces t hr ough t he St at e’ s hos pi t al r at e s et t i ng s y s t em, t r auma phy s i ci ans do n o t e n jo ys im ila r r e lie f

f o r u n c o m p e n s a te d c a re
. Id

. P ropon e n ts as s er t ed thatt he r at es al l ow ed undert he new m ethodol ogy , w hen a p p lied in th e c o n tex t o f tra u m a p h y sic ian s, re su lted in reim b u rsem en ts “d ram ati ca ll y low er th an the a lr ea d ylow M ed icareG en. 44] 51 fee s chedul e. ” Test i m o nyof A ndr ew N

. Pol l ak, M

. D

. , M ary l and O r t hopaedi c A s s oci at i on, i n s uppor tof Senat e B i l l 728. A ccor di ng t o t es ti m o n yof bot h pr oponent s and opponent s of t he l egi s l at i on w ho appea r ed bef

or e the Legi s l atur e, t he 2001 l egi s l at i on w as di r ect ed t o t he compensa t i on of t r auma phy s i ci ans w hen t heyt r eat ed H M O m e m b e rs
. W h ile it w a s b e f

o re th e L e g isla tu re , the b ill w a s a m e n d e d to t ai l ori tw i t h r es pect t o t r auma phy s i ci ans
. U ndert he or i gi nal versi on of t he 2001 l egi s l at i on, a s i ngl e cl aus e w oul d have be en added t o H G §19- 710. 1( b) ( 1) ( i i ) s peci fy i ng t he r ei m bur s ement for m ul a fort r auma car e pr ovi der s
. U ndert hatpr o v isi o n, r ei m bur s ement of t r auma car e provi der s w oul d have r evert ed t o t he pr e- 2000 for m ul a key ed t o t he U C R r at e – a r at e appa r ent l ybel i eved to b e m o re f

a v o ra b le to th e p h y s ic ia n
. See B ill A n a ly sis f o r S e n a te B i l l 728 ( 20 0 1 ). A Senat e amendm ents ubs t i tut ed a di ffe r ent for m u l a : t r a u ma p h y s i c i a n s wer e t o r e c e i v e e i t h e r 1 4 0 % of t he M edi car e r at e or t he r at e t hatt he H M O had hi s t or i cal l ypai d fort he s er vi ce, w hi cheve rw as gr eat er
. A m endment SB 072 8 /13 7072/ 1. A m e n d m e n ts m a d e in th e H o u se o f D e leg a tes a lso a d d e d c e rta in ob l i gati on s for traum a ph y si ci ans, t raum a center s, and H M O s. T r auma phy s i ci ans w ere obl i gat ed t o pr ovi de addi t i onal d o c u me n t a t i o n o f

t r e a t me n ta tt h e r e q u e s to f t h e HM O; t r a u ma cent er s coul d be r equi r ed t o ver i fyt he cr ede n ti als of t he bi l l i ng pr ovi deras a tr auma phy s i ci an; and an H M O w as r equi r ed t o as s i gn a pr ovi dernum bert o a tr auma phy s i ci an forpurpos es of r ei m bur s ement , att he r eques tof t h at p h y s i ci an. A m endment SB 0728/ 343896/ 1. A s par tof t he H ous e amendm ent s , t he defi ni t i on of “c over ed s er vi ce” w as amended t o del et e the tw o s ubor di nat e cl aus es t hathad condi t i oned the def

i ni t i on upon ref

erral orauthor i zat i on of t he H M O

. W hi l e the l egi s l at i ve r ecor d does not addr es s t hi s par t i cul ar p a rt o f th e H o u se a m e n d m e n t, i ts p u rp o se a p p e a rs e v id e n t in c o n tex t. A t r auma phy s i ci an conf r ont ed w i t h an em er gencym edi cal s i tuat i on in v o lv in g a n H M O m e m b e r w o u ld n o t n e c e ss a rilyh a v e th e b e n e f it of a r efe r r al orauthor i zat i on fr om t he pat i ent ’ s H M O

. W hi l e the H M O c o u ld su b se q u e n tlyp ro v id e th e n e c e ss a rya u th o riz a tio n to m ake the tr eatm enta “c over ed s er vi ce, ” the re qui r ement of r efe r r al oraut h o r i zat i on coul d atl eas tr ai s e a que s t i on as t o w hethert he s er vi ce w as “cove r ed” a nd w hether t he H M O w as obl i gat ed t o pay t he s t atut or yr ei m bur s ement

. A s i n ot her pr ovi s i ons of the H M O l aw r el at i ng t o emer gencys er vi ces , t he alt er at i on of t he def i ni t i on of “c over ed s er vi ce” w as l i kel ydes i gned t o ens ur e thatpr i or a u t h o r i z a t i o n wa s n o ta n o b s t a c l e t o r e i mb u r s e me n to f a t r a u ma5 2 [8 8 O p
. A tt ’y

It would also be at c ross purposes to the ongoingassessment of 5 the provision. The L eg islature has di re ct ed the Mary land Health Care Commi ssion and the HSCRC to conduct a study and makea rec ommendation as to the bala nce billingprohibition in the HM O law. Chapter 250, §2, L aws of Ma ryland 2002. In your letter requestingthis opini on , you indicated that you 6 believe that a patient should be allowe d to enter into a private contract with a physician who is not under contract with the patient’s HMO “ and there fo reno t c ontr a c tually bo un d to a c c ept on ly

theHM O pay

me nt” (continued...) p h y s ic ia n
. See H G § 1 9

- 712. 5( c) ( pr i orauthor i zat i on of H M O not r equi r ed f

o r rei m bur s ement of hos pi t al emer gencyfac i l i t yand p r o v id e r); s ee H G § 1 9

- 7 0 5

. 6 ( c r e a t i n g a p r e s u m p t i o n o f HM O au tho ri za ti o n in ce rt ain c ir cu m stan ce s). T her e i s no i ndi cat i on i n t he l egi s l at i ve r ecor d t hatt he G ener al A s s embl yw as cons ideri ng r ei m bur s ement of non- contr act i ng pr ovi der s ot hert han t rau m a phy s i ci ans
. Sur el y , i f t he G ener al A s s embl yhad i nt ended t o eff ecta r adi cal expans i on of t he bal ance bi l l i ng pr ohi bi t i on ort o el i m i nat e the abi l i t yof pr ovi d ers to e nt er 5 i nto pri vate con t ract s, i t w ou l d have don e so m ore exp l i ci t l y . T hu s, i n ourvi ew , “cove r ed s er vi ce” w i t h r es pect t o s er vi ces per for m ed by pr ovi der s ot hert han t r auma phy s i ci ans s houl d be deem ed t o i ncl ude w hat ever r efe r r al or author i zat i on condi t i ons , i f any , ar e r equi r ed by t he H M O benef

i tpl an. H o w ev er, be caus e the amended ver s i on of t h e d e f i n i t i o n ma yc r e a t e c o n f

u s i o n a s t o t h e L e g i s l a tu r e ’ s i n t e n t , we r e c o mme n d t h a t t h e Gen e r a l As s e mbl y c l a r i f y a p p l i c a t i o n of t he d e f in itio n
.

III C oncl usi on I n ouropi ni on, t he 2001 amendm entof t he de fin i t i on of “cov ered ser vice” i n the H M O l aw w as p art of an ef fortt o incr ease t he compensati o n of t r auma phy s i ci ans w ho t r eatpat i ent s w ho h ap p en to be H M O m ember s
. I tw as noti nt ended t o aff ectt he a b ili tyo f H M O m e m b e rs to e n ter in to p riv a te c o n tra c ts w ith h e a lth car e pr ovi der s
. N orw as i ti nt ended t o af fec tt he r es t r i ct i ons on di r ectbi l l ing orbal ance bi l l i ng of H M O m ember s byot her phy s i ci ans
. H o w ever , beca us e the 2001 l egi s l at i on coul d be r ead

6G en. 44] 53

(...continued) 6 (e mph a sis a dd e d)

. Of c ours e , in a private c ontr a c t, the phy sici an wou ld n o tb e a cc ep t i n g anyHMO pay ment. I f the service by

the out-of- network phy sician wa s authorized by the patient’s HMO, the phy sician would be limit ed to the amount of the H MO pay ment specifie d in HG §19-710.1. lit e ra llyre a d to lim it th e a b ili tyo f H M O m e m b e rs to e n ter in to pr i vat e contr act s w i t h pr ovi der s w ho ar e not t r auma phy s i ci ans , t he G e n e ra l A ss e m b lysh o u ld c lar if yits in ten t w ith a n a p p ro p ria te a me n d me n to f

t h e HM O l a w.

J. Jo sep h C u rran , Jr. A t t or ney G ener al R o b e rt N . M c D o n a ld C hi ef C ouns el O pi ni ons and A dvi ce

E ditor ’s N

ote: T he G ener al A s s embl yl at err evi s ed the l aw t o i ncl ude a ne w defi ni t i on i n H G §19- 701, t hatdefi ni t i on i s di s cus s ed i n 90 O pi ni ons of the At t or ney G ener al29 ( 2005)

. C hapt er440, L aw s of M ary l and 2 0 0 4

.