The Health Insurance Process – When the Patient Gets Stuck
Studies show that ER costs make up the biggest portion of amounts owed from insured and uninsured patients struggling to pay medical bills!
In Network or Not?
Did you know that about 66% of emergency room doctors are independent contractors who may or may not be in your insurance plan? And in a practice called balance billing, any out-of-network provider or lab can bill you for whatever your insurance does not cover. You might receive bills from several entities, some of which you never even met!
What is an out-of-network provider mean? This is a healthcare professional that does not have a contract with an insurance plan. Therefore, the provider does not have to accept the insurance’s allowable amount as payment in full.
Think about the ambulance too. If the ambulance company that takes you to the ER does not hold a contract with your insurance, you could be on the hook for more than $2,000.00 depending on where you live in relation to the ER and what level of care your receive prior to arriving at the hospital. Plus, if your insurance company concludes that an ER visit wasn’t warranted, you might owe even more money.
To avoid these nasty surprises, consider the following strategies:
It might sound rudimentary because it is. Ask your insurer what the plan does and does not cover in the event of emergency care. This includes the ER copay, coinsurance, and deductible – in and out-of-network. Many patients are surprised to learn there are different values for out-of-network care. Some plans even have a tiered payment system. Find out which area hospitals are in network with your insurance. Check with the hospital to see which ER doctors are in network in your insurance plan.
Find out how your plan defines a medically necessary ambulance ride and what is required to appeal a non-payment decision.
EMTs decide which hospital they will take you too but you can request a particular one. Request an in-network doctor when the admission forms are completed. Be aware, however, your insurance may deny the charge if you request a hospital further away and could have been treated at a location nearest you.
If you get a bill for out-of-network charges that you could not prevent because of the emergency, then it’s time to get to work. Ask your insurer if they’ll cover the costs at the in-network rate. Contact the providers and ask what the insurance has already paid and ask them to settle for that or negotiate for a lower amount.
About a quarter of US states have consumer protection laws that restrict providers from balance billing in certain care situations like emergencies. Some laws apply only to certain health plans or certain providers. Contact your state’s insurance department for specifics.
If all this fails, contact your insurance to determine what must be submitted to file an appeal and time limits for filing. Generally, documentation from the provider(s) will be required. In the case of an out-of-network situation, ask the doctor to provide a letter attesting to a good faith effort was made to utilize a contracted provider and no equitable access to such provider existed.
It’s not easy blending thoughts of payment with a medical emergency but it is something you can prepare for.