Wait...what? Out of network problems are gone now?

[MBSC]

Quote:

Originally Posted by Aerides Quote: Originally Posted by Fermion Say you are traveling in Florida but live on the west coast and you break a leg. I wouldn't count on this law for that sort of thing, unless you find it in the fine print. I don't think it's meant for end-to-end event coverage, but the surprise stuff - you roll up to a covered facility but then have non-covered services and staff assigned to you, often while you're in no shape to refuse. I don't think this covers true non-covered stuff like you describe.

The No Surprises Act (NSA) has three main components.

1. Out-of-network physicians at in-network hospitals, as you described.

2. Covered emergency room services at OON hospitals and freestanding ER centers.

Insurance companies are given some discretion in deciding what a layperson thinks is an emergency. My plan considers long bone fractures (arm,leg) and open fractures to smaller bones to be covered emergencies.

3. Post-Stabilization Services.

Quote:

The NSA defines emergency services to include post-stabilization services, except under certain conditions. This means that patients are generally protected from balance bills for post-stabilization services. These services fall under the NSA regardless of where in a hospital such services are furnished; they may be provided as part of outpatient observation or an inpatient or outpatient stay if provided together with emergency services. Post-stabilization services are not treated as emergency services under the NSA if certain conditions are met. Patients could face balance bills for post-stabilization services if the patient’s attending emergency physician or treating provider determines that the patient can travel to an in-network facility using nonmedical or nonemergency transportation but the patient opts to stay at the out-of-network facility; a receiving in-network facility must be within a reasonable travel distance. A patient simply cannot give consent when they are far away from any in-network providers and unable to use nonmedical transportation. The same is true if an individual faces unreasonable travel burdens (such as being unable to afford transport or not well enough to take public transit). These limitations prevent them from giving consent. When a patient cannot consent, the NSA’s protections continue to apply to post-stabilization services and the patient cannot be balance billed. Reference: https://www.healthaffairs.org/do/10....6.903518/full/

[GTFan]

Quote:

Originally Posted by Fermion Are we thinking that this would largely prevent the previous fears of having a major health incident while in the USA but not near your network? Say you are traveling in Florida but live on the west coast and you break a leg. Before this law, they could balance bill you for the care I think?

This was not allowed under the ACA, I think, because emergencies are covered as in-network.

My wife broke her leg in DC in 2015 (while on vacation) and we had Humana ACA then. They covered everything as in-network, even the OON surgeon's fee. Total bill paid by insurance was something like $57k for a 3-day stay and all we paid was $6500 deductible.

[Chuckanut]

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Originally Posted by RetMD21 AMA is standing with the doctors and services that have surprise billing as a business model. Unfortunate but not unexpected.

This makes me want to become and automobile mechanic. Every time a M.D. or medical center administrator brings his car in for service, I'll use the same logic on him. " Dr. Achenbach, here's your bill for the new water pump $853. $240 to install the pump, $125 for the pump, and the rest is for the guy who tested and restored your coolant to the proper water/coolant ratio. He's an independent coolant specialist with a certificate from the Joplin Tech Academy. Not one of my regular shop staff."

[subwayhamster]

This will be my first year with an ACA plan and am a bit confused about the changes resulting from the law, specifically the part about post-stabilization services. I was under the impression that before this law went into effect, if you were vacationing in another State and happen to end up as an inpatient in the hospital after receiving care in their ER, you would be responsible in full for the inpatient part of the bill. From my reading of the Health Affairs article quoted earlier, it seems that now (from my point of view as an ACA plan recipient) that same inpatient stay is covered in-network if you cannot feasibly return to your State for in-network care (I'm choosing to ignore the 'impoverished' part of that rule). Is this your understanding as well? Am I right in thinking that I will not need to buy travel insurance for the medical coverage each time I vacation domestically in the US? (I'm not concerned about minor costs like urgent care clinic visits, just the cost for inpatient stays following ER care.) The new law sounds pretty good and very timely (at least to me in my first year of ACA). Thanks for your input!

[Fermion]

Sounds pretty good, you can't be billed if you are not able to be stabilized enough to use non emergency transportation.

So if you can't fly, you can't be billed.

[RetMD21]

Quote:

Originally Posted by disneysteve The out of network issue at an in network facility has always been a problem. If my in network surgeon is operating on me at an in network hospital, how am I supposed to know the the contracted anesthesia group at that hospital is out of network? Or that the contracted radiologist who read my CT scan done at that in network hospital is out of network? It's not like I get to pick and choose those things.

Hospitals can require contracted specialists to participate in the networks but it hasn't necessarily been in their interests to do so.

[travelover]

Quote:

Originally Posted by travelover The petty crooks wear hoodies, the big crooks wear suits.

Quote:

Originally Posted by RetMD21 Hospitals can require contracted specialists to participate in the networks but it hasn't necessarily been in their interests to do so.

[ERhoosier]

Quote:

Originally Posted by RetMD21 AMA is standing with the doctors and services that have surprise billing as a business model. Unfortunate but not unexpected.

You misplace the blame which really belongs more on health care systems.

The vast majority (~70%) of US doctors are now employees, not private practitioners with control over their businesses.

https://www.modernhealthcare.com/pro...s-report-finds

And, FWIW- The AMA has dwindled down over the years to now representing under 20% of practicing US doctors (by membership). It has actually become somewhat of a fringe group these days.

https://www.medpagetoday.com/opinion...ls-scoop/80583

[RetMD21]

Quote:

Originally Posted by ERhoosier You misplace the blame which really belongs more on health care systems. The vast majority (~70%) of US doctors are now employees, not private practitioners with control over their businesses. https://www.modernhealthcare.com/pro...s-report-finds And, FWIW- The AMA has dwindled down over the years to now representing under 20% of practicing US doctors (by membership). It has actually become somewhat of a fringe group these days. https://www.medpagetoday.com/opinion...ls-scoop/80583

Yeah, as I said a fringe group that represents the grifters

[RetMD21]

Here's the CMS template for waiving your surprise billing rights. It looks like it would be hard to miss https://www.cms.gov/files/document/s...g-consumer.pdf

[FLSUnFIRE]

Not a lawyer but the thing I don't get is in general contracts needs certain elements to be enforceable. Meeting of the minds... having a layman sign sheet after sheet of documents that are in legalese most of which they do not understand hardly satisfies a meeting of the minds to me. Which brings me to another thing, the patient/guardian, is getting these forms while under duress of a real/perceived medical emergency and in general, contracts entered into under duress may not be enforceable especially when with huge differential in the power and sophistication of the parties. I just find it unseemly at best and near criminal at worst.


I do my DD when I can but in an emergency that can be near impossible. So far, I've been pretty happy with my insurance and providers but have only dealt with "emergency" situations with my ex-wife and probably got a little lucky.



Not a king either, but if I was king for a day, I'd have menu pricing with standardized definitions/terminology, all parties pay the same, no negotiated prices (for gov't, insurance co, anyone, no exceptions with big penalties). Patients are to told up front the total to be billed and can better choose facilities that are cost effective. Insurance would clearly state how much they'll pay (either in $ or percent) for each service/drug regardless of provider using the same terminology. This would generate some cost competitiveness and eliminate some of the leaches/middlemen.