Health Insurance Billing Games: How Not To Be Gouged – Part 2

Originally published by William K. Berenson.

Car Wreck Victims Should Not Be Harmed A Second Time

To add to the unknown insurance company procedure I blogged about on Wednesday – how injured victims often have to repay their health insurance companies for their medical care after they have been crashed into – here’s another serious problem that affects any one crashed into in Dallas-Fort Worth.

What if you have to go to the nearest hospital to treat your pain and assess your injuries and it is

A. Out of network — and you are billed for its full rate of $5,000?

B. In network and bills your health insurance carrier the $5,000, but your Aetna plan only pays the reduced rate of $1,000,– and you are billed for the balance of $4,000?

C. In network, but the ambulance, emergency room physician, x-ray technician, radiologist, pharmacist and consulting doctors are all out of network — and you are billed for $10,000?

D. In network, but you haven’t met your deductible or can’t afford the co pays, often 20% or more?

We often see clients’ bills of $10,000 or more — just for that first day. The ambulance bill alone in Fort Worth is routinely $1,500 or more.

You won’t even know this until a month later when you receive “balance bills” — or worse, complete bills — leaving you with excessively high amounts. And the other driver’s insurance company won’t pay these until you or your injury lawyer settles the case or a jury awards you damages after a trial.

What should you do? Here are some useful tips.

Protecting Yourself from a Balance Billing Surprise

• Choose providers in your plan’s network if possible.  Consult your provider director to find out who is on your plan.
• Find out in your plan’s summary of benefits if you need prior authorization or a referral from your primary care physician if you have to see a specialist.
• Ask your insurance company to estimate the cost of your medical procedure before receiving it. Calculate what your deductible and coinsurance (co pay) will be and what your share of the expenses will be.
• Use online sites like the TDI Reimbursement Rates and Texas Health Compare for more information on health care cost and quality.
• Get your insurer involved right away. Your insurer may be able to negotiate reasonable fees on the spot.
• Immediately contest your bill. Your insurer may agree to pay the refuted amount or the hospital may waive the balance billing amount.
• Know that an HMO or EPO cannot balance bill if the care was due to a medical emergency or if there weren’t any preferred providers available to treat you. In a PPO, you may be balance billed even for emergency services, but your expenses will count toward your in-network deductible and out-of-pocket maximum. If your balance-billed charges from a hospital-based provider are more than $500, you may request mediation.

It’s Time for Texas Law to Protect Patients

The current laws put the interests of insurance companies and hospitals above the rights of patients.

The Consumer Union reported that one-third of the 2,200 patients it surveyed received a balance billing with unexpectedly uncovered care. Thanks to The Dallas Morning News for writing about this problem yesterday.

The AARP has joined the other groups to lobby the Texas legislature for laws that protect patients from surprise balance bills. A law may be introduced in the next session. Don’t hold your breath that it will be passed.

Nine states already have laws that require insurers and health care providers to negotiate a fair out-of-network fee. In Texas, the patient has to initiate a mediation process. Who knows how to do that?

It is time for our state legislators to stop this pernicious problem.

Curated by Texas Bar Today. Follow us on Twitter @texasbartoday.

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