You work hard. You are responsible. You purchased health insurance. You went to the hospital for an emergency visit. Your insurance will take care of it, right? Maybe not. We see more and more people who have been left with devastating medical bills after an emergency visit to the hospital. This can happen for several different reasons.
One way that you can left with a hefty tab after a hospital visit is something called balance billing. Balance billing occurs when a health care provider is out-of-network for your health insurer. When a provider is in-network, they are forced by their contract with your insurance company to accept the amount that the insurance company pays as full payment for their services after any deductibles and copays have been applied. For example, the medical provider normally charges $5,000 for an MRI, but they have agreed with your insurer that they will accept $3,500 for MRIs from the insurer. If your health care provider is in-network, they will accept the $3,500 as payment for the MRI and you will not owe anything else to the provider.
However, when a health care provider is out-of-network, they do not have an agreement with your insurance company to accept the rate the insurance company pays. That means that they can take the money from the insurance company and then bill you for the rest. This creates problems because in emergencies it is more difficult for people to choose which medical providers they utilize. In addition, any major health procedure will involve several different health care providers, including the hospital, the emergency room physicians, any specialist, the radiologists, the anesthesiologist, and the ambulance, to name a few common ones. Some of these providers may be in-network and some may not be. To make matters worse, a provider might be in-network at one moment and then out-of-network the next. This nearly happened with UAB and United Healthcare in Birmingham. In addition, sometimes insurers and providers misrepresent to policyholders that they are in-network. All of these factors can cause balance billing to occur.
Let’s take a look at an example. A young woman has to have a potential life saving double mastectomy to fight her breast cancer. She calls her doctor’s office who confirms with the insurer that the doctor and hospital are in-network. Unfortunately, this statement is wrong and the hospital is not in-network. The insurer then pays the physician who accepts payment for the full amount. The hospital, who is out-of-network, takes the payment and then charges the patient for the remaining $50,000 balance! The patient cannot pay the bill and is then sent to collections and is eventually sued by the debt collector. The problem of balance billing is exaggerated by the fact that hospitals out-of-network or listed charges often are inflated and bear no resemblance to the rates that they accept for the same procedures when the hospitals are in-network. Often they can be inflated by as much as ten times. For these reasons, balance billing creates big problems.
Blue Cross Denies The Claim
Another common way that someone can receive a surprise medical bill occurs when Blue Cross and Blue Shield of Alabama or a similar health insurer denies the claim. Often health insurers will deny claims saying that services are not medically necessary, are cosmetic, or are experimental. For example, Blue Cross uses a company called New Directions to review its mental health care decisions. New Directions might decide that inpatient hospital care for anorexia is not medically necessary, even when the patient’s own doctor has explained thoroughly that it is necessary. In this case, unless the patient appeals to the determination, the patient will not get the necessary care or the patient will have to pay for it with their own money.
A woman has lipedema, which is a disorder that causes the growth of renegade fat cells that are resistant to diet and exercise. For example, if left untreated the condition can cause massive accumulation of fat on the lower body and lead to loss of movement, as well as severe pain. One of the most effective forms of treatment is a type of liposuction performed by trained specialists in the disease. It is not done for cosmetic reasons, but to reduce pain, restore movement and treat the disease. However, Blue Cross may deny the claim, stating that the procedure was done for cosmetic reasons rather than medically necessary, despite physicians’ letters to the contrary. Again, unless the patient appeals, they could be left holding the bill for the entire amount. Of course, these denials are not limited to these two situations but can occur whenever health insurers try to make medical decisions for their policyholders and substitute their medicals judgment for that of the doctor.
Short Term Health Plans & Association Plans
A third situation that can leave a person holding massive medical bills involves short term health insurance and association plans. These types of insurance plans market themselves as affordable major medical coverage. However, they do not have the guarantees afforded by traditional health care policies provided by employers or through the healthcare marketplace. They often have extensive pre-existing condition limitations, contain high deductibles, limit reimbursement amounts, and omit coverage for maternity leave or mental health. To make matters worse, even when they do cover procedures, the insurers in this group can be aggressive about denying claims for lack of medical records or due to pre-existing conditions.
With regulatory changes in the last couple of years, these policies are on the rise. We have sued these insurers and have blogged about them extensively. You can read more about them here.
What Can I Do About This?
Due to the increasing numbers of Americans affected, surprise bills have been receiving a lot of attention lately. Luckily, many states have begun to act and Congress is considering how to address this issue. Unfortunately, Alabama has not acted yet. As a result, I urge you to contact your state and federal legislators and urge them to address the surprise medical bill problem. Also, you can contact the Alabama Department of Insurance. They sometimes can help with individual complaints and also can conduct investigations when large problems show up in the insurance market. If you have any questions or want help with your insurance claims, please contact us. Together we can address your situation and assist with surprise medical bills.
Contact Our Attorneys Today
If you need legal help regarding surprise medical bills, you need the services of a skilled attorney. We can help by reviewing your situation and advising you of your options going forward.
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The articles on this blog are for informative purposes only and are no substitute for legal advice or an attorney-client relationship. If you are seeking legal advice, please contact our law firm directly.