Help! Help! Out-Of-Network Emergency Woes

Last year, I developed an antibiotic-resistant infection on my arm when I was traveling on the East Coast.

With each day, it grew scarier and more painful, and it was spreading.

Like a good girl, I called my health insurance company here in California and they pointed me to specific urgent care clinics, assuring me I’d only have to pay my regular office co-pay ($20) even though I was visiting an out-of-network provider.

More than a year later, I am still battling the insurer, which billed me the out-of-network price. To add to this infuriating saga, the health plan sent me into collections. (I’ve won the latest battle, and I hope the war, too. But I thought the same thing months ago.)

I have devoted recent columns to the limited doctor and hospital networks that accompany some of your new health plans. This has spurred several of you to ask if you’ll be billed for going out of network when you need emergency care, especially if you’re not in your hometown when the emergency happens.

As my example shows, this issue predates Obamacare. But with more Californians insured now, some by plans with narrow networks, I wouldn’t be surprised if, like me, more of you end up having to duke it out with your insurer.

I’m also sorry to report that some policy holders are more likely to get big bills than others. Read on, if you can stomach it.

Q: What are the best strategies for addressing emergency situations given “in-network” and “out-of-network” coverage? If you are in a car accident, is there any way to avoid bankruptcy?

A: In theory, it shouldn’t matter much whether you visit an in-network or out-of-network emergency room if you have a medical emergency. You may not even have a choice if you’re suffering a heart attack or you’re in other real trouble. The ambulance is going to take you to the closest ER that can handle your situation.

In reality, your bill will depend on what kind of health plan you have and which state agency regulates your plan.

Yes, dear readers, there are two California agencies that regulate health insurers and their products: The Department of Insurance(CDI) and the Department of Managed Health Care (DMHC).

Why we have – or need – two is fodder for another column. But for our purposes, what’s important is that the Department of Insurance regulates most PPO and EPO policies and DMHC oversees managed care policies, but also some PPOs and EPOs.

(To find out which agency regulates your plan, call the CDI consumer hotline at 800-927-HELP.)

No matter which agency regulates your plan, the Affordable Care Act says you will be charged the same co-pay (which is a flat dollar amount) for visiting an out-of-network emergency room as an in-network one, says Janice Rocco, CDI deputy commissioner.

If your share of the bill comes in percentages instead, you will be charged the same ratio (say 20 percent) regardless of the ER’s network status. In these circumstances, however, you may face a higher dollar amount because your insurer may not have negotiated rates with out-of-network ERs or physicians like it has with in-network ones, Rocco notes.

In plain terms, that means you may be billed 20 percent of $10,000, for instance, instead of 20 percent of $2,000.

That’s not the worst of it for the roughly 10 percent of Californians whose plans are regulated by CDI. Ever hear of something called “balance billing”? Sometimes health plans and the hospitals/doctors that provide the services don’t agree on the amount that providers should be paid.

“Balance billing” occurs when the doctors and/or hospitals bill the consumer directly for the difference between what the plan pays them and what they think they’re owed.

If you have a CDI-regulated plan, you may be balance billed for out-of-network use.

“Efforts to change this in the Legislature have failed,” Rocco says.

Dr. Tom Sugarman, an emergency physician who practices in the Bay Area, provides an example:

Let’s say you show up in the emergency room with a complex fracture, and the doctor who assesses you needs to call in an orthopedist. Even if you’re at an in-network hospital, that orthopedist may not be in your network.

Sugarman says insurance companies often don’t pay enough for the services of specialists, so you may be balance billed for that care.

“Physicians in general would like to never balance bill,” he says. “But if it’s an unreasonable payment the insurance companies come up with, the doctors have no choice.”

Kind of sucks, huh?

For the majority of Californians whose health plans are regulated by DMHC, balance billing for emergency services is not allowed, says the agency’s Marta Green.

“Any dispute over payment is between the provider and the plan, and the enrollee cannot be placed in the middle,” she says.

But it’s still possible to receive an incorrect bill even if you have a plan regulated by DMHC, like I did. Your plan may, for instance, argue that you weren’t really having an emergency and that you didn’t need to seek out-of-network emergency care.

So here’s some advice:

• Know which hospitals are covered by your plan and go to an in-network provider if you possibly can. “That will be the safest thing for financial risk,” Sugarman says.
• If you receive a bill in the mail from a provider for out-of-network emergency services that you believe is incorrect, dispute it with your insurer.
• If that doesn’t resolve the problem, file a formal appeal with your insurer.
• If you’re still stuck, call CDI’s hotline (number above) or DMHC’s Help Center (888-466-2219).

My final suggestion is to call or email your legislators and ask them to change the law so all Californians have the same protection against balance billing.

Provided by the Center for Health Reporting at the University of Southern California.

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