![]() And unless you live in one of the 10 or so states where balance billing is limited or prohibited, you may be on the hook for that amount. At that point, the out-of-network provider may bill the patient for the balance that the insurer didn’t pay. The provider bills the insurer, and the insurer – which has no contract with the doctor or hospital – pays what it considers a reasonable rate for the area and the service. The new law continues to allow out-of-network providers to “balance bill” patients for amounts the insurer doesn’t pay. But the new federal law covers all types of plans, including those of self-insured companies that pay their employees’ health claims directly and are exempt from state insurance regulations.Ĭonsumers may face a potentially more troubling problem, however. Nearly every state already has laws prohibiting such “prior authorization,” says Timothy Jost, a law professor at Washington and Lee University in Lexington, Va. The law also says that people can’t be required to seek approval from their health plan before getting emergency care. ![]() Eventually, many of those existing plans are expected to lose their grandfathered status – by amending their plans beyond allowable limits – but for now they don’t have to comply. Note, however, that the provisions apply only to new health plans, not existing ones that are grandfathered under the law and exempted from some regulations. 23, but plans are not required to implement the change until the beginning of the new insurance plan year. The law is designed to prohibit insurance plans from charging higher co-payments or coinsurance amounts for out-of-network emergency services or from imposing other coverage limitations that would not apply to in-network care. Under the new health-care law, you may not have to be a medical billing expert to avoid many out-of-network charges for emergency care. “We see this kind of problem all the time,” she says. Butcher was in a better position than many to fight the charge: She’s chief executive of Medical Billing Advocates of America, which helps consumers fight coverage denials and underpayments. Butcher successfully disputed the charge, arguing for a 40 percent discount because the hospital she went to was in network and because the discounted figure was about what an in-network fee would have been. It included a $750 out-of-network charge for the physician assistant’s services. She drove five minutes to the emergency room near their home in Salem, Va., where a physician assistant cleaned the wound and closed it with two staples. ![]() Often unbeknownst to patients, some of the doctors and other providers at their in-network hospital may themselves be out of network and not under contract to a particular insurer.Ĭandice Butcher ran into this problem last year when her son Logan, then 2, collided with a dining room chair and opened up a deep gash on his head nearly three inches long. This can be a problem even if you break your leg in your back yard rather than skiing at Vail. More From This Series: Insuring Your Health ![]()
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