Current Events > Ban on Surprise Medical Billing - Took Effect 12-30-2021

(+) Yeah! (+)

I don't know if this was talked about or not but:

https://www.nytimes.com/2021/12/30/upshot/medical-bill-ban-biden.html

This was BIPARTISAN legislation. Ever go to the ER and you pay your copay and you see a doctor for whatever the issue is. But then two specialists come in for a minute each that are out of network and you get a bill for 1000 dollars. Or you get surgery but SURPRISE the anesthesiologist was out of network and now you have a bill for 3000 bucks. Why are you getting this bill? Because those random people were out of network.

Not anymore.

If you are having a medical emergency and go to an urgent care center or emergency room, you cant be charged more than the cost sharing you are accustomed to for in-network services. This is where the laws protections are the simplest and the most clear for people with health insurance.

It even offers some protection for Air Ambulance (but not regular ambulance) trips.

This is 100 percent a great thing. Hospitals and doctors will bitch but honestly, fuck them. This practice of having out of network practitioners at an in network hospital only screws over patients. Someone in a car accident shouldn't be worrying about making calls to their insurance to make sure each person that comes into their room is in network or not.

I worked in Health Insurance for a few years and some of that time I spent taking phone calls from people who had our insurance. You would get several of these calls daily asking about why they are getting a surprise bill and the only answer we could ever give them was basically "that sucks, gotta pay it."

That's great, but I can't help but wonder how hospitals are going to find another way to screw patients over due to this. Maybe they'll charge patients more upfront.

WrkHrdPlayHrdr posted...

I worked in Health Insurance for a few years and some of that time I spent taking phone calls from people who had our insurance. You would get several of these calls daily asking about why they are getting a surprise bill and the only answer we could ever give them was basically "that sucks, gotta pay it."

Same. I'm in that industry now. What a racket

In network is such a scam.

Awesome news, thanks for sharing!

I should also say that you should read the article yourself and look other places. I'm sure there's small print details that I haven't included in a quick write up.

@WrkHrdPlayHrdr

i have a question.

my wife and I are expecting a baby in February. He has to have a surgery 3 months later.

we were referred to by multiple doctors to go to CHOP because they have world renowned specialists for his issue.

we both have good insurance. I have Magnacare and she has Empire Blue Cross.

apparently the hospital doesnt take either of our insurances because we are out of state/network. CHOP is in Philly and we work in NY.

we are fearing that after all is said and done we will be incurring a medical bill of at least 100k.

how should we approach our insurance company about this if we get a bill? Apparently it wont be covered. but why do we have insurance then?

going to another hospital is non negotiable as the surgery requires him to be sedated at 3 months old and a lobe of his lung be removed. So we want the best in the field to obviously perform this procedure and even her doctor said the same.

A child qualifies you to reregister for insurance I think. Thats gotta be considered a life changing event.

Maybe you can pick a different provider they do take there?

Yeah I know CHOP. It's only like an hour and a half away.

A disclaimer - This isn't actual advice and you should always get your final answer from your insurance company. (Meaning, your best bet is to call them)

Health Insurance networks are weird. With Blue Cross / Blue Shield plans each company has their own small network. Empire BC has a network in NY. Highmark (the big PA BC/BS plan and the company I used to work for) has a network in PA. The BC/BS plans all work together and share networks for their PPO plans. Meaning if you have BC/BS insurance in NY if the BC/BS plan in PA is in network with CHOP then they are in network for you as well.

One thing you want to check is your card. Does it have a small briefcase logo with the letters PPO in it? If yes, then it's a PPO plan and what I said above is more than likely true for you. HOWEVER, if you don't have a PPO plan this changes things.

This led me to check the CHOP website. Below is a screen cap from their website. I think you can safely ignore the note about CHOP Home Care since that isn't what you're doing. However, the part I highlighted does kind of worry me. It seems like they might NOT be in network.

https://gamefaqs.gamespot.com/a/user_image/7/6/6/AAdVIJAACxbu.png

This second picture is also from their website and specifically talks about the whole PPO network sharing thing I mentioned above. "Blue Card" is the system in which BC/BS insurers share networks. This seems to indicate you might have coverage.

https://gamefaqs.gamespot.com/a/user_image/7/6/7/AAdVIJAACxbv.png

My final answer is that I can't tell you 100 percent if you have coverage or not. Your best bet is to have the hospital name, address, and the name of the OB/GYN who will probably be doing the delivery and ask them. What they will do is probably put you on hold and call Highmark (PA BC/BS) to check if CHOP is in network with them and then come back and tell you the answer. But again, this depends on you having that PPO briefcase logo.

I'm sorry I can't help more. If I still worked there I would have access to the computers and could tell you. I will say this is all based on you possibly having a BC/BS PPO plan. I didn't even get into your other insurance since I'm not familiar with it. I will say though that their website doesn't have Magnacare listed.

Edit: I should also note, and this is good advice for anyone who has a BC/BS PPO from an out of state company.... When you call a doctors office to check network status do not ask them if they are in network with your BC/BS plan. (In your example if you call a doctor in PA don't ask if they are in network with Empire. They will have no idea. The correct question you want to ask is "are you in network with the local blue cross/blue shield plan" and if you have the PPO plan and they say yes then they are in network for you.

Additional aside: Don't ever ask if they "accept" your insurance. Accept doesn't mean the same thing as in-network. You'll find a lot of out of network providers will say they accept all insurances but all that means is they will gladly take whatever money the insurance company will pay them as an out of network provider, but they will still come to you for the balance due. If they are in-network they can't come after that balance.