Posted on 11/12/2014 4:46:38 PM PST by SMGFan
Must be the worst insurance in the world to not pay for out of network emergency.
Well clearly I had the wrong insurance, because there were doctors and hospitals in and out of my network long before Obamacare showed up.
Had she gone to the in-network hospital, she’d only have been hit with about $1,500 in expenses. But since she was taken to the other hospital, she now has to pay the huge difference between what her insurance company paid the hospital and what the hospital charges.
The hospital that treated her billed the patient for $254,000. Her insurance company paid $156,000, which is 100% of what it would have paid to an in-network hospital. That left a balance of $98,000, which the hospital slashed after negotiations with the patient, but still leaves her with bills from individual physicians, the ambulance service and other charges.
Anthem is pointing the finger at the hospital, saying that the insurance company can’t control the prices at a hospital it doesn’t have a contract with.
For one thing, I would like to point out that there is actually a difference in a provider or hospital “accepting” your insurance plan and a provider or hospital “participating” in your insurance plan. In this situation the out of network hospital was willing to accept payment from her insurance company to the tune of $156k but since the hospital didn’t “participate” in her insurer’s plan, they won’t accept the insurer’s in-network fee schedule as payment in full and are therefore free to balance bill the patient for the difference. When you are looking for a doctor, make sure to ask if he/she “participates” in your insurance plan and not merely “accepts” your insurance.
Of all the numerous things to hate about ACA (Obama Care), this is not one of them.
This sort of thing happened long before “Obama Care” and in fact one of the provisions if ACA is that insurers must pay for out of network ER visits, apply to their deductible, co-pays and co-insurance and out of pocket maximums the same as if in-network, were as prior, in some cases, the insurer wouldn’t pay anything to the out of network hospital or pay anything without a pre-authorization, although most would cover at least to the in-network coverage level if the patient truly had a medical emergency, i.e. was incapacitated and taken by ambulance to the nearest available ER even if out of network.
But I also know personally of a few cases where the patient (my brother was one) was taken to the ER via EMT ambulance because at the time they believed it was an urgent life or death situation (i.e. shortness of breath, chest pains) but after the trip the ER and examination and tests, it was found it was something like severe indigestion and not a “true” emergency. The insurance company(s) in those cases refused to cover the ER visit because it was not deemed to be an emergency (but only after the fact) and the patient didn’t call to get a “pre-authorization”.
From Anthem’s website:
Emergency room services – In the event of an emergency, this provision allows individuals to seek emergency room services from in or out of network emergency rooms without pre-authorization for services (post-treatment notification requirements are permitted).
Insurers must cover out-of-network emergency room services, and copayments and coinsurance for these services cannot exceed those for in-network emergency room services. Other types of cost sharing (e.g., deductibles and out-of-pocket limits) are allowed on out-of-network ER if it is the same cost sharing as imposed on other out of network benefits. Health plans must pay the out of network provider the greater of the following: their median payment to in-network ER providers, the amount that would be paid if the plan used the same method for ER as it uses for other out of network services, or the amount that would be paid by Medicare. Members can continue to be balanced billed by the out of network provider.
http://www.anthem.com/provider/noapplication/f1/s0/t0/pw_b148225.pdf?refer=ahpprovider
This is not the fault of her insurance company as they paid as per her plan provisions and contract, exactly what they would have paid for an in-network hospital, but is the out of network hospital playing hard ball with the “balance billing” and not accepting her insurance company’s “in-network” payment as payment in full.
If I were her, I would (or have my attorney) look into what insurance plans this hospital does participate in and what those insurers would pay for the very same services in-network. If those insurance plans with whom the hospital and attending physicians do participate in, pays less than my insurance at the in-network reimbursement, I would tell them, I will only pay that difference. OTHO if those insurance plans with whom the hospital and providers participate in, pay more, I would tell them they need to reimburse my insurance company for the difference. It might not work but I’d tie them and their billing department and attorneys up good and long enough that that they might be willing to negotiate more and bring down that $50k balance to nearly nothing.
Didn’t see your ‘facts’ there, either. Now I have to go wash my computer.
Thank you for your reasonable and factual response. Obamacare sucks. But not all that ails healthcare is because of Obamacare. And blaming everything on Obamacare only makes us look silly.
Thanks - Hospital is being a dick!
Geez, what’s with the facts? Nobody wants to hear that. It’s ALL Obama’s fault. Or maybe Hillary.
Inviting the Daily Kos in to your home pegs the meter.....
https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/
Just a reminder if you get sick away from your network.
The out of pocket max does not apply...
Cardiac arrest means she was dead. The ambulance had to go to the nearest hospital by law. The ER saved her life. She is upset about her life being saved?
The HMO Act written by Teddy K needs repealing. HMO's have all but destroyed affordable care and true private insurance coverage. It became a huge money maker for parent insurers who own most of them. Jack up actual insurance policy cost {which requires covering it's risk} and offer instead a rationing system.
The person was unable to communicate and had she been able to do so under those conditions it would not have mattered. She was going where Trauma Protocol dictated. This system is done to save lives and so the responders and hospitals have an orderly system to go by. There is no corporation I loathe more, none is more corrupt and influences government more than Insurers. Many are corrupt to their very core. I'd go as far as to say over 75% plus of the laws and codes on the books were written solely to lessen the insurers monetary losses.
Opps my mistake. His Highness King Teddy’s HMO Bill exempted Hey Moe from litigation.
In Texas, you have a different deductible for out of network services, but once it is met, the insurance carrier must pay (albeit usually with a different coinsurance rate).
However, if the patient has no viable choice for selecting an out of network provider (and an emergency situation is an example commonly cited), then the insurance carrier must pay the claim as though it were in network -- same deductible, co-payment and coinsurance.
Bottom line: Either the lady is incredibly stupid and ill-advised, or there is a lot more to the story than what is being reported here.
It's so 1994 to be looking up providers in phone books. Seriously.
She was in no condition to sign a contract before her treatment. Therefore, her max should be her plan's maximum out of pocket.
She should transfer any assets she has to her boyfriend and stonewall the hospital!
“Almost every time what the insurance pays is different than what you would without insurance. IE, you get SCREWED”
Indeed. If you pay cash, the thieving, liberal vultures who run these hospitals will charge you 200 to 400% more than what they charge insured patients.
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