Emergency Room Surprise?

Posted on June 28th 2017 in Health Plans

What's with this separate doctor's bill?

ER Room

California Assembly Bill 72 Out-Of-Network Coverage and Member Cost-Sharing  California Assembly Bill 72 Out-Of-Network Coverage and Member Cost-Sharing

I cannot begin how many patients call us and say, "I went to the emergency room but all of a sudden, I have this bill from the doctor!  What gives?"

Even if you saw your regular doctor in the ER before July 1st, you would get a bill from your doctor and his emergency room union for his services.  Surprise!

However, effective July 1, 2017, a new state law protects patients from receiving unexpected "surprise or balance" medical bills from an out-of-network doctor, i.e. an emergency room doctor or anesthesiologist, when receiving inpatient and outpatient care and services at an in-network healthcare facility such as a hospital, clinic, lab, imaging center or other healthcare facility. 

So now, when individuals go to an in-network facility for care but receive services from an out-of-network doctor or healthcare provider, they only have to pay their in-network cost-sharing amount that counts toward the annual deductible and annual out-of-pocket maximum limits according to their health plan. More importantly, these out -of-network doctors should only bill you after you and they have received a copy of the Explanation of Benefits reflecting the correct in-network cost-sharing amount owed.  If for any reason the out-of-network doctor or healthcare provider receives payment that is more than the cost share allowed, the out-of-network doctor must refund the overpayment within 30 days.

Yup, this is all really confusing but count on us to help make sense when the time comes.  Until you do, don't pay an excessive bill until we can look at it.  darcy@americashealthadvocates.com