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HelloThis 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.
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.
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.
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.
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