Ask Emily: Help! Out-of-network emergency woes

CHCF Center for Health ReportingJuly 1, 2014 

Emily Bazar writes for the CHCF Center for Health Reporting, answering questions about the Affordable Care Act. Read all her columns at sacbee.com/askemily.

CHCF CENTER FOR HEALTH REPORTING

Ask Emily is a biweekly column by Emily Bazar of the CHCF Center for Health Reporting, answering questions about the Affordable Care Act. Read all her columns at sacbee.com/askemily .

Last year, I developed an antibiotic-resistant infection on my arm when traveling on the East Coast. With each day, it grew scarier and more painful, and it was spreading.

Like a good girl, I called my health insurance company here in California and they pointed me to specific urgent care clinics, assuring me I’d have to pay only my regular office copay ($20), even though I was visiting an out-of-network provider.

More than a year later, I am still battling the insurer, which billed me the out-of-network price. To add to this infuriating saga, the health plan sent me into collections.

I have devoted recent columns to the limited doctor and hospital networks that accompany some of your new health plans. This has spurred several of you to ask if you’ll be billed for going out of network when you need emergency care, especially if you’re not in your hometown when the emergency happens.

As my example shows, this issue predates Obamacare. But with more Californians insured, some by plans with narrow networks, I wouldn’t be surprised if, like me, more of you have to duke it out with your insurer.

Read on.

What are the best strategies for addressing emergency situations given network and out-of-network coverage? If you are in a car accident, is there any way to avoid bankruptcy?

In theory, it shouldn’t matter much whether you visit a network or out-of-network emergency room if you have a medical emergency. You may not even have a choice if you’re suffering a heart attack or in other real trouble. The ambulance will take you to the closest ER that can handle your situation.

In reality, however, your bill will depend on what kind of health plan you have and which state agency regulates your plan.

There are two California agencies that regulate health insurers and their products: The state Department of Insurance (CDI) and the Department of Managed Health Care (DMHC).

Why we have – or need – two is fodder for another column. For now, what’s important is that the CDI regulates most PPO and EPO policies and DMHC oversees managed care policies, but also some PPOs and EPOs. (To find out which agency regulates your plan, call the CDI consumer hotline at (800) 927-HELP.)

No matter which agency regulates your plan, the federal Affordable Care Act says you will be charged the same copay (a flat dollar amount) for visiting an out-of-network emergency room as a network one, said Janice Rocco, CDI deputy commissioner.

If your share of the bill comes in percentages instead, you will be charged the same ratio (say 20 percent) regardless of the ER’s network status. In these circumstances, however, you may face a higher dollar amount because your insurer may not have negotiated rates with out-of-network ERs or physicians as it has with network ones, Rocco noted.

In plain terms, that means you may be billed 20 percent of $10,000, for instance, instead of 20 percent of $2,000.

That’s not the worst of it for roughly 10 percent of Californians whose plans are regulated by the CDI. Ever hear of “balance billing”? Sometimes health plans and the hospitals/doctors that provide services don’t agree on the amount that providers should be paid.

Balance billing” occurs when doctors and/or hospitals bill the consumer directly for the difference between what the plan pays and what the medical providers think they’re owed.

If you have a CDI-regulated plan, you may be “balance billed” for out-of-network use.

Dr. Tom Sugarman, a Bay Area emergency physician, provides an example: Let’s say you show up in the emergency room with a complex fracture and the ER doctor needs to call in an orthopedist. Even if you’re at a network hospital, that orthopedist may not be in your network.

Sugarman said insurance companies often don’t pay enough to cover the services of specialists, so you may be balance billed.

“Physicians in general would like to never balance bill,” he said. “But if it’s an unreasonable payment the insurance companies come up with, the doctors have no choice.”

For the majority of Californians whose health plans are regulated by DMHC, balance billing for emergency services is not allowed, said the agency’s Marta Green.

“Any dispute over payment is between the provider and the plan, and the enrollee cannot be placed in the middle,” she said.

But it’s still possible to receive an incorrect bill even if you have a plan regulated by DMHC, like I did. Your plan may, for instance, argue that you weren’t really having an emergency and that you didn’t need to seek out-of-network emergency care.

So here’s some advice:

•  Know which hospitals are covered by your plan and go to a network provider if you can. “That will be the safest thing for financial risk,” Sugarman said.

•  If you receive a bill from a provider for out-of-network emergency services that you believe is incorrect, dispute it with your insurer. If that doesn’t resolve the problem, file a formal appeal with your insurer.

•  If you’re still stuck, call CDI’s hotline (number above) or DMHC’s Help Center at (888) 466-2219.

My final suggestion is to call or email your state legislators and ask them to change the law so that all Californians have the same protection against balance billing.

Questions for Emily: AskEmily@usc.edu

Learn more about Emily here .

The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism , it is funded by the nonpartisan California HealthCare Foundation .

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