Where's my medical billing experts at?
May 25, 2018 2:14 PM Subscribe
I have a very specific medical billing question: Is balance billing legal in California, for ER care, with a PPO, at an in-network facility, for an out-of-network doctor?
So that's what it boils down to. I'm having trouble finding a firm answer.
So: Kid BlahLaLa had a situation requiring emergency care. Was taken by ambulance to ER #1 where he was stabilized, later transfered to ER #2, admitted, surgery, etc. Lots of bills, lots of tests, procedures, imaging, providers, etc. Both facilities were in-network. There's one pesky invidual doc in ER #1 who turns out to be out of network.
I see California AB72. It does not relate to emergency room care.
I see references to "older statues" that protect Californians from balance billing for ER care but can't find details.
I see references to Prospect Medical Group, Inc. v. Northridge Emergency Medical Group (2009) 45 Cal.4th 497 -- but we are in a PPO not an HMO.
I see that balance billing for Medicare patients in CA is outlawed; but this isn't Medicare.
Further details, not sure if they matter, but:
That doc is, let's say, billing my insurance $2000.
My insurance (Blue Cross) says: it's out of network, so ordinarily we pay 50% of the allowed amount, but since it's for the ER, we pay 90% of the allowed amount. The allowed amount is $1000. So we'll give the doc $900.
Doctor sends me a bill for $1100.
I ask insurance co about it. They say there's nothing they can do, but I should try telling doc I'll pay the remaining 10% of the allowed amount, so $100.
I propose this to doctor's billing office, they say no. But they're willing to cut a deal, so I only have to pay them $800. They will entertain a dispute letter from me, but before I send that, I am trying to get clear about the law. If I don't legally need to pay more than the 10%, I don't want to.
Help, please? But again -- please note the very specific parameters of this question.
So that's what it boils down to. I'm having trouble finding a firm answer.
So: Kid BlahLaLa had a situation requiring emergency care. Was taken by ambulance to ER #1 where he was stabilized, later transfered to ER #2, admitted, surgery, etc. Lots of bills, lots of tests, procedures, imaging, providers, etc. Both facilities were in-network. There's one pesky invidual doc in ER #1 who turns out to be out of network.
I see California AB72. It does not relate to emergency room care.
I see references to "older statues" that protect Californians from balance billing for ER care but can't find details.
I see references to Prospect Medical Group, Inc. v. Northridge Emergency Medical Group (2009) 45 Cal.4th 497 -- but we are in a PPO not an HMO.
I see that balance billing for Medicare patients in CA is outlawed; but this isn't Medicare.
Further details, not sure if they matter, but:
That doc is, let's say, billing my insurance $2000.
My insurance (Blue Cross) says: it's out of network, so ordinarily we pay 50% of the allowed amount, but since it's for the ER, we pay 90% of the allowed amount. The allowed amount is $1000. So we'll give the doc $900.
Doctor sends me a bill for $1100.
I ask insurance co about it. They say there's nothing they can do, but I should try telling doc I'll pay the remaining 10% of the allowed amount, so $100.
I propose this to doctor's billing office, they say no. But they're willing to cut a deal, so I only have to pay them $800. They will entertain a dispute letter from me, but before I send that, I am trying to get clear about the law. If I don't legally need to pay more than the 10%, I don't want to.
Help, please? But again -- please note the very specific parameters of this question.
I have some peripheral involvement with health insurance. On a generic level if the doctor is out of network he has no contract with the insurance company requiring him to accept the negotiated rate. However, I"m not sure but I'm wondering if there is also an issue that you received a package of treatment at the hospital that you believed would be in-network and that you were not given the advance information and opportunity to consent or deny treatment by an out of network provider.
Seconding that the Department of Insurance is your best bet for unbiased information.
posted by metahawk at 5:55 PM on May 25, 2018
Seconding that the Department of Insurance is your best bet for unbiased information.
posted by metahawk at 5:55 PM on May 25, 2018
Response by poster: Thanks for the answers so far.
Just to make this even more difficult, it turns out that my insurance plan (happens to be via union) isn't overseen by my state's Dept. of Insurance, or its Dept. of Managed Health Care. It's overseen by the US Department of Labor, Employee Benefits Security Administration. And dealing with the Department of Labor is...not easy.
Here's the only thing I could find on their website. I can't interpret it. Help?
Out-Of-Network Emergency Services
Q15: Public Health Service Act (PHS Act) section 2719A generally provides, among other things, that if a group health plan or health insurance coverage provides any benefits for emergency services in an emergency department of a hospital, the plan or issuer must cover emergency services without regard to whether a particular health care provider is an in-network provider with respect to the services, and generally cannot impose any copayment or coinsurance that is greater than what would be imposed if services were provided in network. At the same time, the statute does not require plans or issuers to cover amounts that out-of-network providers may “balance bill”. Accordingly, the interim final regulations under section 2719A set forth minimum payment standards in paragraph (b)(3) to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of- network emergency service provider who, in turn, could simply balance bill the patient.
Are the minimum payment standards in paragraph (b)(3) of the regulations intended to apply in circumstances where State law prohibits balance billing? (Similarly, what if a plan or issuer is contractually obligated to bear the cost of any amounts balance billed, so that the patient is held harmless from those costs?)
A15: No. As stated in the preamble to the interim final regulations under section 2719A, the minimum payment standards set forth in paragraph (b)(3) of the regulations were developed to
5
protect patients from being financially penalized for obtaining emergency services on an out-of- network basis. If a State law prohibits balance billing, plans and issuers are not required to satisfy the payment minimums set forth in the regulations. Similarly, if a plan or issuer is contractually responsible for any amounts balance billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimums. In both situations, however, patients must be provided with adequate and prominent notice of their lack of financial responsibility with respect to such amounts, to prevent inadvertent payment by the patient. Nonetheless, even if State law prohibits balance billing, or if the plan or issuer is contractually responsible for amounts balance billed, the plan or issuer may not impose any copayment or coinsurance requirement that is higher than the copayment or coinsurance requirement that would apply if the services were provided in network.
posted by BlahLaLa at 6:49 PM on May 25, 2018
Just to make this even more difficult, it turns out that my insurance plan (happens to be via union) isn't overseen by my state's Dept. of Insurance, or its Dept. of Managed Health Care. It's overseen by the US Department of Labor, Employee Benefits Security Administration. And dealing with the Department of Labor is...not easy.
Here's the only thing I could find on their website. I can't interpret it. Help?
Out-Of-Network Emergency Services
Q15: Public Health Service Act (PHS Act) section 2719A generally provides, among other things, that if a group health plan or health insurance coverage provides any benefits for emergency services in an emergency department of a hospital, the plan or issuer must cover emergency services without regard to whether a particular health care provider is an in-network provider with respect to the services, and generally cannot impose any copayment or coinsurance that is greater than what would be imposed if services were provided in network. At the same time, the statute does not require plans or issuers to cover amounts that out-of-network providers may “balance bill”. Accordingly, the interim final regulations under section 2719A set forth minimum payment standards in paragraph (b)(3) to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of- network emergency service provider who, in turn, could simply balance bill the patient.
Are the minimum payment standards in paragraph (b)(3) of the regulations intended to apply in circumstances where State law prohibits balance billing? (Similarly, what if a plan or issuer is contractually obligated to bear the cost of any amounts balance billed, so that the patient is held harmless from those costs?)
A15: No. As stated in the preamble to the interim final regulations under section 2719A, the minimum payment standards set forth in paragraph (b)(3) of the regulations were developed to
5
protect patients from being financially penalized for obtaining emergency services on an out-of- network basis. If a State law prohibits balance billing, plans and issuers are not required to satisfy the payment minimums set forth in the regulations. Similarly, if a plan or issuer is contractually responsible for any amounts balance billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimums. In both situations, however, patients must be provided with adequate and prominent notice of their lack of financial responsibility with respect to such amounts, to prevent inadvertent payment by the patient. Nonetheless, even if State law prohibits balance billing, or if the plan or issuer is contractually responsible for amounts balance billed, the plan or issuer may not impose any copayment or coinsurance requirement that is higher than the copayment or coinsurance requirement that would apply if the services were provided in network.
posted by BlahLaLa at 6:49 PM on May 25, 2018
Response by poster: But what I think I understand there...doesn't apply to my situation. My insurance co. isn't asking me for $, the doc is.
posted by BlahLaLa at 6:51 PM on May 25, 2018
posted by BlahLaLa at 6:51 PM on May 25, 2018
This is a highly-regulated area and I am loathe to try to interpret just a fragment of a regulation, but it sounds like, if California does NOT ban balance billing, your insurance would therefore be required to pay at least the minimum payment established by that (b)(3). You need to look at (b)(3) to see if that $900 payment meets that minimum payment standard.
That section sounds like it is actually intended to deal with your exact situation. The insurance company isn't allowed to charge you more than the in-network co-pay or coinsurance. But the rule doesn't itself ban balance billing, which means that the doctor can still come after you for additional payments for the services. In order not to make the first part of the rule a nullity, the regulation establishes minimum payment standards that the insurance company must meet. Depending on how those standards are determined, that might make the rule only slightly less than a nullity or fully protective. Probably closer to the former than the latter, as they could probably have banned balance billing and protected you completely and didn't, but still might be better than the hypothetical $900.
posted by praemunire at 9:09 PM on May 25, 2018
That section sounds like it is actually intended to deal with your exact situation. The insurance company isn't allowed to charge you more than the in-network co-pay or coinsurance. But the rule doesn't itself ban balance billing, which means that the doctor can still come after you for additional payments for the services. In order not to make the first part of the rule a nullity, the regulation establishes minimum payment standards that the insurance company must meet. Depending on how those standards are determined, that might make the rule only slightly less than a nullity or fully protective. Probably closer to the former than the latter, as they could probably have banned balance billing and protected you completely and didn't, but still might be better than the hypothetical $900.
posted by praemunire at 9:09 PM on May 25, 2018
The info I am finding states pretty strongly this is illegal in California (I am not a lawyer, I am not a medical billing expert, I did not sleep in a spiffy hotel last night, but I do have some insurance experience):
8. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation, 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.
https://www.beckershospitalreview.com/finance/30-things-to-know-about-balance-billing.html
Balance billing is illegal in California...
The provider cannot bill the patient but must work out payment with the health plan.
https://www.bestattorney.com/resources/balance-billing.html
posted by DoreenMichele at 11:42 PM on May 25, 2018
8. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation, 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.
https://www.beckershospitalreview.com/finance/30-things-to-know-about-balance-billing.html
Balance billing is illegal in California...
The provider cannot bill the patient but must work out payment with the health plan.
https://www.bestattorney.com/resources/balance-billing.html
posted by DoreenMichele at 11:42 PM on May 25, 2018
It looks like AB72 would normally cover ER care at an in network facility, but unfortunately not for your health plan:
“Now that AB 72 is in effect, Imholz said California has some of the nation’s toughest laws on surprise billing.
“Fifteen have some protections against balance billing, but just six have comprehensive protections. California’s are especially strong,” she said.
But there are still some caveats.
The biggest is the fact that California’s regulations don’t include “self-insured” health plans regulated by the U.S. Department of Labor under the Employee Retirement Income Security Act of 1974. That federal legislation covers about 40 percent of those with commercial insurance in the Golden State.”
source
posted by Wavelet at 9:35 AM on May 26, 2018 [1 favorite]
“Now that AB 72 is in effect, Imholz said California has some of the nation’s toughest laws on surprise billing.
“Fifteen have some protections against balance billing, but just six have comprehensive protections. California’s are especially strong,” she said.
But there are still some caveats.
The biggest is the fact that California’s regulations don’t include “self-insured” health plans regulated by the U.S. Department of Labor under the Employee Retirement Income Security Act of 1974. That federal legislation covers about 40 percent of those with commercial insurance in the Golden State.”
source
posted by Wavelet at 9:35 AM on May 26, 2018 [1 favorite]
Response by poster: Right. That seems to be the catch -- If it was an HMO I'd be okay. If it wasn' the ER I'd be okay. But in the ER, with a PPO. SOL?
posted by BlahLaLa at 10:12 AM on May 26, 2018
posted by BlahLaLa at 10:12 AM on May 26, 2018
I'm no expert, just someone in California who spends a lot of time on the phone with insurance companies and health care providers thanks to our various random family ER runs: in the past, when we've run into balance billing issues, it was our insurance company that ended up getting the out of network health care provider to lay off. As you are now excruciatingly well aware, it's impossible to go to any hospital without having 50 different medical professionals touch and bill you, some of which are doubtless out of network or possibly not in any network at all. Your health insurance company SHOULD be helping you with this, it's what you pay them for. Unfortunately since your health insurance is governed by the US department of labor, it looks like protections for other PPOs in California may not apply to you, but here is what I would try:
You can call your insurance and try to get someone competent on the phone to explain IF an out of network provider is allowed to balance bill you in an ER situation, and if NOT, can the health insurance get involved to let them know to knock it the heck off.
You can call the CA Insurance commission hotline: http://www.insurance.ca.gov/
I would try getting a definitive answer from the CA Insurance commission to see if you are legally obligated to pay, or if you can tell the provider to pound sand. And really, your insurance company should be the one to tell them to pound sand.
posted by Wavelet at 8:52 PM on May 26, 2018
You can call your insurance and try to get someone competent on the phone to explain IF an out of network provider is allowed to balance bill you in an ER situation, and if NOT, can the health insurance get involved to let them know to knock it the heck off.
You can call the CA Insurance commission hotline: http://www.insurance.ca.gov/
I would try getting a definitive answer from the CA Insurance commission to see if you are legally obligated to pay, or if you can tell the provider to pound sand. And really, your insurance company should be the one to tell them to pound sand.
posted by Wavelet at 8:52 PM on May 26, 2018
Also, per this, Blue Cross in CA should prohibit balance billing, and the DHMC is the place to call for clarification.
“In October 2008, California's Department of Managed Health Care (DMHC) set rules to restrict balance billing for emergency services, but only for the products they regulate (e.g., HMOs, Blue Cross PPOs and Blue Shield PPOs). ”
posted by Wavelet at 9:03 PM on May 26, 2018
“In October 2008, California's Department of Managed Health Care (DMHC) set rules to restrict balance billing for emergency services, but only for the products they regulate (e.g., HMOs, Blue Cross PPOs and Blue Shield PPOs). ”
posted by Wavelet at 9:03 PM on May 26, 2018
Response by poster: Unfortunately I think you guys are running around the same cirlces I was. My insurance company has nothing to say on the matter. My insurance plan isn't under the jurisdiction of the DHMC or the CA Dept. of Insurance -- both of whom are super attentive on the phone but have to pass me along to the Dept. of Labor.
posted by BlahLaLa at 11:41 AM on May 27, 2018
posted by BlahLaLa at 11:41 AM on May 27, 2018
I can't speak to the law in CA, but the "allowed amount" would only exist for providers that have a contract with the payer (insurance co). IF the doc doesn't have a contract with the insurance company, then you'd be SOL on that front and the doc could bill whatever amount they want without restriction from insurers.
posted by WeekendJen at 10:09 AM on May 29, 2018
posted by WeekendJen at 10:09 AM on May 29, 2018
I have found customer service for the blues to be....willing to say anything true or not to get you off the phone.
posted by WeekendJen at 10:10 AM on May 29, 2018
posted by WeekendJen at 10:10 AM on May 29, 2018
Yes, this is one reason that insurance policies must be set at Federal Level. States are not permitted to regulate insurance provided under ERISA plans (like your union plan.)
Under the regulation you cited above, you could argue that you will pay the contracted amount for this service under your insurance plan, not "List Price."
posted by ohshenandoah at 10:21 AM on May 29, 2018
Under the regulation you cited above, you could argue that you will pay the contracted amount for this service under your insurance plan, not "List Price."
posted by ohshenandoah at 10:21 AM on May 29, 2018
Response by poster: Putting this here just in case it's useful to someone in the future:
Yep, it's threading a regulatory needle but for ERISA health insurance, at an ER which is in-network, you are responsible for the out-of-network individual provider's balance billing.
It's not my insurance company's fault -- they've already paid more (90%) than they usually pay out of network (50%) in appreciation of the fact that this was an emergency.
It's not a matter for the CA Department of Insurance or the CA Department of Managed Care, because it's ERISA.
Sucks balls.
posted by BlahLaLa at 4:44 PM on June 12, 2018
Yep, it's threading a regulatory needle but for ERISA health insurance, at an ER which is in-network, you are responsible for the out-of-network individual provider's balance billing.
It's not my insurance company's fault -- they've already paid more (90%) than they usually pay out of network (50%) in appreciation of the fact that this was an emergency.
It's not a matter for the CA Department of Insurance or the CA Department of Managed Care, because it's ERISA.
Sucks balls.
posted by BlahLaLa at 4:44 PM on June 12, 2018
Best answer: Adding this update. The only way I got anyone to help me was:
-- I left a one-star Yelp review for the hospital, and briefly outlined the situation, stating "very good health care, terrible billing practices, hidden out-of-network physician
-- Hospital replied via Yelp, said "We want to help! Call us!"
-- When I called, Hospital said, "Oops, sorry, we can't help! It's not us, it's the doctor!"
-- I updated my Yelp review to say "Don't be fooled by hospital stating they'd help; they didn't."
-- Two weeks of nothing.
-- Hospital higher-ups contacted me and said "We actually do want to help you, but..." and before they could launch into "It's not us, it's the doctor" I showed them that I understood the situation and would only talk to them if they intended to actually help me.
-- Believe it or not, they helped me. I don't know what went on behind the scenes, but they leaned on the doctor to adjust the billing. So, I will end up paying 10% of the "customary charge" for the procedure, my insurance already having paid 90% of that number. It's about $1000 less than the doctor wanted. So, a win.
posted by BlahLaLa at 6:17 PM on July 26, 2018 [4 favorites]
-- I left a one-star Yelp review for the hospital, and briefly outlined the situation, stating "very good health care, terrible billing practices, hidden out-of-network physician
-- Hospital replied via Yelp, said "We want to help! Call us!"
-- When I called, Hospital said, "Oops, sorry, we can't help! It's not us, it's the doctor!"
-- I updated my Yelp review to say "Don't be fooled by hospital stating they'd help; they didn't."
-- Two weeks of nothing.
-- Hospital higher-ups contacted me and said "We actually do want to help you, but..." and before they could launch into "It's not us, it's the doctor" I showed them that I understood the situation and would only talk to them if they intended to actually help me.
-- Believe it or not, they helped me. I don't know what went on behind the scenes, but they leaned on the doctor to adjust the billing. So, I will end up paying 10% of the "customary charge" for the procedure, my insurance already having paid 90% of that number. It's about $1000 less than the doctor wanted. So, a win.
posted by BlahLaLa at 6:17 PM on July 26, 2018 [4 favorites]
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posted by praemunire at 5:02 PM on May 25, 2018