There was a time in my life I absolutely hated surprises, particularly ones that put me at the center of attention. I am not proud of the fact that I once walked out on a surprise party that was thrown for me. I have grown up a bit since then.
However, when an individual is hospitalized and later finds out that some of the doctors who provided treatment during the hospital stay are not covered because they are not in the network; that is not a fun surprise.
When an individual starts receiving all the bills and insurance company explanations of benefits (EOB) following a hospital stay, they are often overwhelmed. There are bills from providers that they never remembered seeing, let alone asking if they were PPO providers.
This happened most often in an Emergency Room (ER) encounter. If it is truly an emergency, there is likely some stress around the event. So the patient and family are proud of the fact that they remembered to choose a network hospital as they were speeding to the ER.
The first shock they will have is when they realize that the ER bill will likely be in the thousands of dollars. They may have waited hours to see a doctor, then longer for the tests. But actual time with the doctor is often rather short.
One of my favorite stories is from a client who took his son to the ER for stitches after the young man had sliced his hand with a knife. His wife had insisted they need to go to the ER.
When they received the $3500 ER bill, he went a little bit crazy. This man is accustomed to suturing his livestock and tending to all manner of little emergencies on the job, as he is a fireman as well. He simply could not grasp the concept of charging so much for so what her perceived to be so little. He swore next time he would suture any wounds himself! Fortunately for him the physician was “preferred provider” in his plan’s network! Emergency room physicians’ charges have been some of the biggest issues with this type of problem.
As stated in Legislative Counsel Digest regarding this bill: Existing law requires a health care service plan to reimburse providers for emergency services and care provided to its enrollees, until the care results in stabilization of the enrollee. Existing law prohibits a health care service plan from requiring a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the enrollee’s emergency medical care, as specified.
It’s critical to understand the Emergency room is typically staffed and equipped to handle advanced trauma, so they charge accordingly. We advise our clients to avoid the ER if at all possible.
But back to our inpatient stay. Let’s first assume this is not an emergency stay. You have done your homework. Your hospital and surgeon are both PPO providers. But, you get a bill from the anesthesiologist and find out s/he is not a network member. You never even thought about checking that out. You are not alone.
As agents, we are typically the ones who assist clients with this type of issue. Whether the claim was an emergency or you simply had no idea the provider was not in network, you do have recourse such as filing an appeal.
Our professional association, CAHU (California Associate of Health Underwriters) has worked for nearly 16 years to have legislation that will protect clients in this situation. Finally such a law has been passed and is on the desk of Governor Brown. AB 72 is bi-partisan consumer protection legislation aimed at helping protect you from unexpected balance billing if you are treated by an out-of-network provider at an in-network facility.
While the intent of this column is not political, I think it’s important to inform you of legislation that is important to you. In this case, I am asking that you write to Governor Brown and encourage him to sign it. You can do so at: https://govnews.gov.ca.gov/gov39mail/mail.php. If signed, it will be effective 7/1/2017.
One important caveat in the law allows you to sign away this right. It reminds me of the situation we have with colonoscopies here in town. So make sure you read the fine print when you sign the hospital admission papers to be sure you are not signing away your rights to be free from balance billing!