By Emily Bazar of the OC Register, very good info-
Last year, I developed an antibiotic-resistant infection on my arm when 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 have to pay only my regular office copay ($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 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, some by plans with narrow networks, I wouldn’t be surprised if, like me, more of you have to duke it out with your insurer.
What are the best strategies for addressing emergency situations given network and out-of-network coverage? If you are in a car accident, is there any way to avoid bankruptcy?
In theory, it shouldn’t matter much whether you visit a 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 in other real trouble. The ambulance will take you to the closest ER that can handle your situation.
In reality, however, your bill will depend on what kind of health plan you have and which state agency regulates your plan.
There are two California agencies that regulate health insurers and their products: The state Department of Insurance (CDI) and the Department of Managed Health Care (DMHC).
Why we have – or need – two is fodder for another column. For now, what’s important is that the CDI 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 federal Affordable Care Act says you will be charged the same copay (a flat dollar amount) for visiting an out-of-network emergency room as a network one, said 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 as it has with network ones, Rocco noted.
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 roughly 10 percent of Californians whose plans are regulated by the CDI. Ever hear of “balance billing”? Sometimes health plan and the hospitals/doctors that provide services don’t agree on the amount that providers should be paid.
“ Balance billing” occurs when doctors and/or hospitals bill the consumer directly for the difference between what the plan pays and what the medical providers think they’re owed.
If you have a CDI-regulated plan, you may be “balance billed” for out-of-network use.
Dr. Tom Sugarman, a Bay Area emergency physician, provides an example: Let’s say you show up in the emergency room with a complex fracture and the ER doctor needs to call in an orthopedist. Even if you’re at a network hospital, that orthopedist may not be in your network.
Sugarman said insurance companies often don’t pay enough to cover the services of specialists, so you may be balance billed.
“Physicians in general would like to never balance bill,” he said. “But if it’s an unreasonable payment the insurance companies come up with, the doctors have no choice.”
For the majority of Californians whose health plans are regulated by DMHC, balance billing for emergency services is not allowed, said 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 said.
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 a network provider if you can. “That will be the safest thing for financial risk,” Sugarman said.
• If you receive a bill 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 at (888) 466-2219.
My final suggestion is to call or email your state legislators and ask them to change the law so that all Californians have the same protection against balance billing.
From Emily Bazar of the OC Register-
What good is it to have a health plan if you can’t find doctors and hospitals to accept it?
That question rushes to mind every time a frustrated reader writes in to describe his or her Kafkaesque quest to find care.
I’m also hearing from frustrated medical providers, including Dr. Nelson Branco, a pediatrician in Marin County Branco was one of more than 2,300 California doctors who participated in a survey conducted by the California Medical Association (CMA) in April.
The survey found that 80 percent of those who responded were, at some point, confused about their participation in health insurance exchange. sold by Covered California, the state’s
That was “at some point.” Right now? One in five doctors remains confused.
Poor consumers! What chance do you have to find a doctor in your network if doctors themselves don’t know?
In today’s column, I’m sorry to have to describe yet another pitfall that could complicate your ability to receive care from a doctor who participates in your
Q: I bought a Blue Shield plan, which my physician is on. But the only hospital where my doctor has privileges is not contracted with Blue Shield. Is this problematic?
As a matter of fact, yes.
Let’s say you need surgery. Your doctor, who is in your network, plans to perform the procedure at a nearby hospital, the only hospital where she has privileges.
You do a little homework (because that’s what you have to do in this new insurance environment), and you discover that the hospital isn’t in your plan’s network.
As more Californians start to use their new health insurance, they’re finding these kinds of doctor and hospital mismatches: Sure, there may be hospitals in your network. But they’re not necessarily the ones to which your physician can admit patients.
These mismatches often are a result of newly created “narrow networks” that have limited doctor and hospital choices for plans bought through Covered California or on the private market. These networks were created by some health insurance plans to save money: Insurers pay fewer providers lower fees but promise them higher volumes of patients in return.
(Not that networks were unlimited before. But now, some are substantially smaller.)
In when children need urgent care in the evening or on weekends, the county’s pediatricians refer them to a specific after-hours clinic, Branco says.
But Branco’s patients who purchased an Anthem Blue Cross plan through Covered California can’t get in-network coverage at the clinic. Even though Branco contracts with Anthem, the clinic does not.
Faced with the prospect of paying out of pocket, some parents simply take their children to the emergency room, a much more costly form of health care, he says. (And one that defeats two major goals of Obamacare: Reducing unnecessary care and lowering costs.)
“It’s really a mess,” the pediatrician says. “The after-hours clinic has kept thousands of patients out of the ER and saved thousands of untold ER dollars. Now, to limit access to the after-hours clinic is really just shooting ourselves in the foot.”
Hospitals are complaining about mismatches, too, says Dietmar Grellmann of the California Hospital Association.
“If a throws networks together and doesn’t take the time to sort through the physician admitting relationships (with hospitals), you get these kind of mismatches,” he says.
Lindy Wagner of Blue Shield of California says mismatches shouldn’t occur because the networks “were designed to include physicians with admitting privileges to hospitals in the network.”
Blue Shield is working with doctors to clear up confusion about their participation in plans and is continually adding doctors to its network, she says.
That’s all great. But it is happening.
What are consumers to do now?
The most critical time to do your homework on networks is before you buy a plan, Grellmann says.
“When consumers sign up for Covered California, they really need to do some due diligence, not just shop for the cheapest product,” he says. “The days of signing up for a plan and expecting everything to go great are probably over.”
Grellmann acknowledges that confusion and misinformation reigned during open enrollment and that it was very difficult for consumers to decipher networks at that time.
So now that you’re stuck with a plan, the best thing you can do is verify, verify, verify.
Confirm not only that your doctor is in network, but the hospital, too. Check your information against multiple sources, including your insurer.
And get nosy.
“It may be worth asking your doctor if they have privileges at a network hospital,” says Brett Johnson of the CMA.
If you learn that the hospital or hospitals where your doctor has privileges are NOT in your network, you likely face an unpleasant reality (assuming you don’t want to be out tens of thousands of dollars for going out of network): Switching doctors.
“They’re going to have to make a choice that, from the patient’s perspective, is probably not a good choice,” Grellmann says.