Balance Billing

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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: 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!

Margaret R. Beck
Margaret Beck  CLU, ChFC, CEBS started her insurance practice in Redding in 1978. As an insurance broker/consultant,  she represents businesses and individuals as their advocate.  She assists in choosing proper products, compliance with complex benefit laws and claims issues once coverage is placed. All information in her column is provided to the best of her knowledge, subject to final regulation by the respective agencies. Questions to be answered in this column can be submitted to Beck's column is also published in the Redding Record Searchlight.
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3 Responses

  1. cheyenne says:

    One thing that has happened to me the few times I went to the ER, was that a year later I would receive a bill from some lab on the East Coast saying I owed them $2-$5 for lab tests done in the ER that the insurance had not paid.  I would call them and complain why they waited a year to send me a bill and they replied they were waiting on the insurance.  I have been told, I do not know if it is true but maybe you can tell me, that insurance companies don’t pay bills that are billed a year after the service was rendered.  The amount is so small that it was easier to just pay them than make all the phone calls that would be involved.  Has this every come up with you and if it has is it a scam by the lab?

  2. K. Beck says:

    I went to the ER once because of an auto accident. I was convinced I was OK. Seat belt did it’s job  very well. I had a gash on the back of my head and a broken finger. All went well. They released me. Someone picked me up. I had insurance coverage from my previous employer. All the bills were paid, I thought, my share amounted to a few co-pays. This was over 10 years ago. Years later  I decided to check my credit bureau report, for unrelated reasons, and found there was an unpaid bill from the ER Doc. In collection! NO ONE ever sent me that bill!!! So there it was going against my credit rating. For years! It was not much money and I paid the collection agency right away. So, that is something else people who go to the ER might want to keep an eye on. Maybe it was a co-pay my insurance company didn’t pay and the Doc never billed me? I have no idea. Like Cheyenne, paying was easier than trying to figure out what went wrong.

  3. Joanne Lobeski-Snyder says:

    I love reading your articles Margaret.

    In one month I received a notice that I had been dropped by my insurance company.  The woman I phoned at the company said the letter was a mistake.  The next letter I received stated that my request for a mammogram was denied because a mammogram is not a medical necessity.  I had already had the mammogram a month before I received the letter.  I decided to let the imaging center, who has done my screening for years, and the insurance company who has covered this screening for years to fight it out between themselves.

    I’m beginning to understand why everyone needs the services of an expert like you.  Paying money for insurance is a simple task.  Taking advantage of that insurance is a herculean task for people like myself.

    Thank you for sharing your knowledge.


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