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Sam
Sam, Attorney at Law
Category: Legal
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Experience:  More than 20 years of experience practicing law.
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I received a balance bill from an out-of-network doctor

Customer Question

I received a balance bill from an out-of-network doctor (specialist in plastic surgery) that performed emergency room surgery (stitches) on my son 7/2/14. I had gone to the ER room at the nearest hospital. Subsequently I received an explanation of benefits and a balance bill.
My insurer claims they re-reviewed the claim and paid the out-of-network doctor their highest allowed amount, as an in-network provider. The doctor's office claims they are out-of-network and that I signed paperwork in the hospital saying I'm responsible for anything not covered.
In an EMERGENCY ROOM situation, where a referral is not possible and the patient is captive to whichever doctor is provided by the hospital, are there any laws or rulings that protect the patient from being balance billed? Who would I appeal to? The State of New Jersey Dept of Banking and Insurance?
Submitted: 9 months ago.
Category: Legal
Expert:  Sam replied 9 months ago.

Hello

This is Samuel. I am sorry to hear that your son was injured and I hope he is doing better.

Unfortunately, an Out of Network physician does not need to accept what is paid by any insurance that is not within network. Since they are out of network, there are no contractual obligations to them. While an in network medical provider must adhere and accept the payment because they aren’t allowed to charge any additional fees — a practice called balanced billing — or they’ll be in violation of their contract with your health insurance company.

I wish it was better news. But if you want to file a complaint, I suggest you could begin with the NJ Dept of Banking and insurance commission.

Expert:  Sam replied 9 months ago.

Now, under the Affordable Care Act there is a right to emergency care, even if it’s at an out-of-network hospital, without prior approval from your insurance carrier. You can’t be charged higher copays or coinsurance either. This is one of the 10 essential benefits covered by the ACA. Those services are very limited such as a matter of life and death.

However, once you’re stable, you’ll be transferred to an in-network facility. From that point on you’ll need to make sure all your providers are in-network. Even though this is not the sort of thing you want to worry about when you’re ill or injured, you really don’t want to be hit with a hefty bill for your care down the road.

So if the plastic surgery was not an emergency and it could have been done at a later date by an in network doctor, then you will be responsible for any balance due to the out of network medical provider.

Expert:  Sam replied 9 months ago.

And I know you are saying your son got stitches, but I am sure there is fine print somewhere about a "specialist" in this case a plastic surgeon being out of network and thus not covered under ACA. I suggest you will need to show that the Specialist was the only staff on hand to administer the stitches. If you can show that, then I suggest you have a legitimate claim that there should be no balance.

Expert:  Sam replied 9 months ago.

Because in that case, it was an emergency and with out the stitches your son could have had serious continuing injury or death. In my opinion, this is a sad commentary on our state of affairs as it relates to Obamacare/ACA but it is not much that can be done at this time. Your option is to show the specialist plastic surgeon was the only doctor there who could have stitched him up and it was indeed an emergency matter of life or death.

Expert:  Sam replied 9 months ago.

Please let me know here if you have other questions or need clarification. Otherwise a positive rating ensures I get credit for my time and information in this regard.

Expert:  Sam replied 9 months ago.

Thank you.

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