Writing about health insurance and health care issues cannot be done without reference to politics. This segment of the economy is highly regulated and there is never a time when new laws aren’t being proposed.
The good news is that it appears there is bi-partisan support for federal legislation that will eliminate surprise medical bills. Maybe this will be good practice for legislators to remember how to work together!!
Californians can be grateful that our stated implemented this type of regulation in July of 2017.
Surprise medical bills can take several forms. One might be that an individual has surgery at a hospital that is in the insurance plans Preferred Provider network, but the anesthesiologist was not in network. The anesthesiologist then bills much more than the plan allows and the employee is balance billed for more than their share of the plan’s negotiated rate.
The patient had no control over who delivers the anesthesia and had no way of knowing the doctor was not in the network. When the provider send the extra bill, the patient is surprised…and often quite upset.
If a patient goes to a lab that is in the plan’s network, but the provider who reads the results is not in the network, the patient could receive a surprise bill.
According to the California Dept. of Managed health care, “Under AB 72, consumers should no longer receive these surprise bills. This means when you go to a health care facility like a hospital or a lab in your health plan network, and end up with a doctor who is not in your health plan network, they cannot charge you more than you would have to pay for an in-network doctor.”
If an individual has received a surprise bill paid more than the in-network cost share there are remedies to obtain a refund. The insured may file a grievance with the health plan. This may be done in writing or in some cases simply by calling the customer service number on the plan’s ID card.
If the results of the grievance are not satisfactory, one may file a complaint with the Department of Managed Health Care, (DMHC). This agency is the state regulator of health plan. The website address is: www.HealthHelp.ca.gov and the phone number is 1-888-466-2219.
It’s important to understand that this law applies only to individuals insured by health plans regulated by the Department of Managed Health Care or the California Department of Insurance. It does not apply to Medi-Cal plans, Medicare plans or “self-insured plans.” If the plan type is unclear, the health plan’s customer service number may have the answer or one can call DMHC at the number above.
These rules do not prohibit an individual from voluntarily seeking care from an out of network provider. It is important to check the plan provisions to see how out of network care is covered. There may be separate deductibles for out of network providers. There will likely be a much greater co-insurance or copayment paid by the individual when using an out of network provider. It is important to understand the costs before you choose to go to an out of network provider. The provider should be able to give you an estimate.
Another option would be to request the actual procedure billing codes and charge from the provider, then call the health plan and ask what the share of cost would be based on that information. This will prevent those unwanted surprises.