End of surprise out-of-network billing in CA

[MichaelB]

The ambulance discussion misses the issue. The question is not how expensive the ambulance ride (or anesthesiologist )charge is, but a hospital confirming it is part of an insurance network, then allowing a physician not part of the insurance network to provide services without any type of prior disclosure, cost estimate, or patient approval.

 

[travelover]

The ambulance discussion misses the issue. The question is not how expensive the ambulance ride (or anesthesiologist )charge is, but a hospital confirming it is part of an insurance network, then allowing a physician not part of the insurance network to provide services without any type of prior disclosure, cost estimate, or patient approval.

Yes, but the argument was being made that while the charges were not in-network rates, the charges were totally reasonable because of the seriousness of the service provided. My point with the ambulance driver example is that just because someone is in a position to save your life, the standards of fair compensation don't go out the window.

But if the anesthesiologist makes a mistake you're dead. And that's his job by the way, keeping you just this side of death.

 

[MichaelB]

Yes, but the argument was being made that while the charges were not in-network rates, the charges were totally reasonable because of the seriousness of the service provided. My point with the ambulance driver example is that just because someone is in a position to save your life, the standards of fair compensation don't go out the window.

Got it, and agree. The value of the service provided is a red herring. The question is why is any health service provided under the auspices of the hospital not part of or covered by the same insurance plan and network.

 

[Walt34]

The question is why is any health service provided under the auspices of the hospital not part of or covered by the same insurance plan and network.

I just ran into this last week for a procedure done at the hospital. One of the intake people mentioned that the anesthesiologist was not part of the hospital staff, but a group of anesthesiologists practicing on their own.So I called there, and they did take the same insurance so no surprises.

Apparently they contract themselves out to several local hospitals rather than with only one.

 

[photoguy]

It's official. Jerry Brown signed the bill on friday.

 

[Tadpole]

Self-funded employer plans will be exempt from the California law.

Why? And what percent of Californians are excluded with this exemption?

 

[MBSC]

Why? And what percent of Californians are excluded with this exemption?

In general, self-funded employer plans fall under ERISA health plan regulations and are exempt from state jurisdiction and state regulations. My megacorp legal department received confirmation the state regulation exemption will extend to this new state law. Nationwide, some 60% of employer plans are self-funded.

Edit to add: Found a news article for this.

The bill's provisions would not apply, however, to self-insured employer health plans, which are shielded from state regulations by the federal Employee Retirement Income Security Act.

Health plans would pay non-contracting physicians the plan's average contracted rate or 125% of the Medicare rate, whichever is greater.
http://www.modernhealthcare.com/article/20160901/NEWS/160909980

 

[ziggy29]

In general, self-funded employer plans fall under ERISA health plan regulations and are exempt from state jurisdiction and state regulations. My megacorp legal department received confirmation the state regulation exemption will extend to this new state law. Nationwide, some 60% of employer plans are self-funded.

And in general, the larger the company, the more likely their plan is self-funded.

 

[Options]

California's governor signed this and a bunch of other health laws to go into effect in 2017:

California Governor Signs Flurry Of Health Laws | California Healthline

Of additional interest is SB1076:

SB 1076: This law, sponsored by the California Nurses Association, was designed to protect hospital patients in “observation” care. It requires that observation units meet the same staffing standards — nurse-to-patient ratios — as those in the emergency room.

Outpatient services are not covered by the same patient protection regulations as inpatient units, and many times patients are left in an observations status for a long period of time, according to supporters of the law. In addition, such treatment is not counted toward the three days of hospitalization that Medicare requires for a patient to be covered for nursing home care once they are discharged from the hospital.

No matter what state you're in, check your medical bill. I disputed $350 of unwarranted billing earlier this year and had it reversed:

https://www.washingtonpost.com/national/consider-a-second-opinion-on-that-medical-bill/2016/10/02/cc778ce6-88b9-11e6-8cdc-4fbb1973b506_story.html?_hsenc=p2ANqtz-9Aa40W2AC-16LSn_Mar3fP6u2iP4AV9EbtAbxoF0R9x2F7ioH40ZMJwG-jXcrncBXYzOqOosbGrga_fikaOSkmtzWIIg&_hsmi=35220326&utm_campaign=KHN%3A%20First%20Edition&utm_content=35220326&utm_medium=email&utm_source=hs_email

The American Medical Association estimates that 7.1 percent of bills paid by commercial health insurers contain errors, while others estimate errors are far more common than that.

 

[daylatedollarshort]

We just got an out of network bill for an assistant surgeon at an in network hospital for thousands of dollars - close to five figures. Never heard of the guy, never saw him, didn't know he existed until we got the bill. It was a relatively minor follow up outpatient surgery and so far he has billed our insurance double what the main operating surgeon (the person we actually met and knew was out of network going in) agreed to bill us. And who knows how many of these surprise out of network bills at an in network hospital will keep rolling in.

I am sure the insurance company will pay at last some and I'll negotiate the bill down much further, but it is really depressing that a system even exists where sticker shock like this can happen. This is on top of the over $6K out of pocket max and extra we agreed to pay for a an out of network specialist. No wonder for average Joe's medical bills are the leading cause of bankruptcy in the U.S. (62%).

One of our relatives was asking me to help recently with picking the right policy for travel insurance for a foreign country and I can't even relate to what is enough insurance in almost any other country in the developed world because the U.S charges for everything are so crazy high in comparison, like this chart:

21 Graphs that Show U.S. Health Care Costs are Ludicrous
https://www.washingtonpost.com/news...ow-americas-health-care-prices-are-ludicrous/

 

[sengsational]

I wonder if having a bracelet that said "anyone who attends me agrees that XYZ insurance company's in network rates will constitute payment in full" would help in a court case. If the doc denied having read the bracelet, that would be admitting to breaking protocol, and if the doc read that and didn't excuse him or herself then they have agreed to the terms.

 

[fh2000]

We just got an out of network bill for an assistant surgeon at an in network hospital for thousands of dollars - close to five figures. Never heard of the guy, never saw him, didn't know he existed until we got the bill. It was a relatively minor follow up outpatient surgery and so far he has billed our insurance double what the main operating surgeon (the person we actually met and knew was out of network going in) agreed to bill us. And who knows how many of these surprise out of network bills at an in network hospital will keep rolling in.

I am sure the insurance company will pay at last some and I'll negotiate the bill down much further, but it is really depressing that a system even exists where sticker shock like this can happen. This is on top of the over $6K out of pocket max and extra we agreed to pay for a an out of network specialist. No wonder for average Joe's medical bills are the leading cause of bankruptcy in the U.S. (62%).

One of our relatives was asking me to help recently with picking the right policy for travel insurance for a foreign country and I can't even relate to what is enough insurance in almost any other country in the developed world because the U.S charges for everything are so crazy high in comparison, like this chart:

21 Graphs that Show U.S. Health Care Costs are Ludicrous
https://www.washingtonpost.com/news...ow-americas-health-care-prices-are-ludicrous/

Your profile says you are in California. Did the new law have no effect on your charges, or this was issued before the governor signed the bill?

 

[cathy63]

Your profile says you are in California. Did the new law have no effect on your charges, or this was issued before the governor signed the bill?

The new CA law goes into effect on July 1, 2017.

 

[daylatedollarshort]

Your profile says you are in California. Did the new law have no effect on your charges, or this was issued before the governor signed the bill?

We just got the bill, but as cathy63 pointed out the law does not go into effect until next year, so I don't know if it will help us for services in 2016.