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Emergency Care Billing Provisions for Health Insurance Take Effect September 23rd – Out Of Network Charges No Longer Subje

Posted May 21 2010 11:03am

In the case of an emergency, you may not have time to consult and see what hospital is in network, depending on what the emergency is.  This has been a huge on going battle for years, and especially felt big time in California, lawsuits over this issue too, and a study showed that one of of every six claims for emergency image department care was denied by 2 large HMOs in California. 

A life saving event at the ER should not force people into bankruptcy and yet it has happened time and time again.  Prime Healthcare was one such example which lead this investigation all over the place.  Patients were receiving balance due bills and basically they just wanted their charges paid, but a lot of folks caught in the middle of all of this and hopefully this is one situation that will go away too. 

“Dr. Reddy states Kaiser should pay the bills, not the patient. "We really don't want the patients to pay us," Reddy said. "Patients are the only messengers to the health plans. They should call and say, 'We paid you dearly, how come you don't pay for my emergency care?'

Prime Healthcare almost has no contracts in place at their hospitals but do provide emergency services at their ER Rooms.  When your life is threatened and you need immediate care, the last thing on anyone’s mind is “are they in network”.   In New York there are also related battles going on in regards to being notified by the hospital or the reimbursement will be cut in half and this may go beyond emergency treatment too, but again just more unrest in how we get care sometimes.

Perhaps as some of the new provisions of healthcare reform go into place we might begin to see some standardization of charges become more transparent too.  BD

When Kelly Arellanes fell off a horse and suffered a severe head injury in rural Arkansas, medics said she would need to be airlifted immediately to the nearest hospital — 50 miles away in Fort Smith. There, emergency surgery saved her life — but at a cost.

The hospital wasn't in her insurance network, so she and her husband ended up with $20,000 in out-of-pocket expenses that they wouldn't have incurred at their network hospitals 150 miles away in Little Rock.

If the new health law had already been enacted, Arellanes wouldn’t have had such a big emergency bill. Under the law, insurance companies must extend several new protections to patients who receive emergency care. One of the biggest guarantees: insurance companies can no longer pay less for emergency care at “out of network” hospitals — the hospitals with which they don’t have prior financial arrangements.

The new law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the "prudent layperson" rule. For example, if a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense.

Kelly, now 50, has gone through intense rehabilitation and needs tests and checkups every few months. Without her salary and battered by the bills from the emergency room and continuing medical costs, the family burned through their savings, retirement accounts, investments and their daughter's college fund. With medical debts of more than $100,000, they filed for bankruptcy in 2005.

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