Insurance company won’t pay entire medical bill? New state rules will help
What is balance billing?
After her breast cancer recurred in late 2016, the Oceanside woman became hospitalized at Scripps Memorial in
Herron was astounded to later receive a bill from
The
"I wasn't told beforehand that I was going to be billed for that. It just came out of the blue," said Herron, 63.
This was an example of balance billing, also known as "surprise billing."
"These kinds of surprise bills can occur when an out-of-network service is provided at an in-network facility like a hospital," said
In other words, the hospital where the patient is staying may be under contract with that person's insurance company -- so it's considered an in-network arrangement. But certain surgeons, anesthesiologists, radiologists, ambulance companies and others providing service at that hospital may not be part of the network, and they can charge rates higher than the usual contracted amounts. The patients are billed for whatever portion, the remaining balance, their insurance companies won't cover.
In 2015,
The survey helped spur action in
Last year, the Legislature passed Assembly Bill 72, which forbids balance billing for out-of-network care at in-network facilities. The law took effect on
Some of the most common balance-billing situations involve anesthesiology and imaging services delivered in settings that range from hospitals to labs to stand-alone imaging centers, according to the state
The new law complements older
"Fifteen have some protections against balance billing, but just six have comprehensive protections.
But there are still some caveats.
The biggest is the fact that
And given that out-of-network balance billing has been going on for a long time, there are bound to still be some cases of the practice occurring today -- in violation of the newly rolled out AB 72.
"We tell people not to panic. Call your plan and the provider to clarify the situation, and don't pay anything unless you've gathered all the information," Imholz said.
Insurance companies are required to accept grievances for suspected inappropriate billing and have 30 days to resolve the problem.
It looked to be too late for Herron, the Oceanside resident with the
Then last week, after
A spokesman for
For others faced with a medical bill they don't think adds up, Herron counseled persistence.
"Scream and make a lot of noise. It might work," she said.
The state
In addition, the
(619) 293-1850
Twitter: @paulsisson
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