I don’t want to make this sound like I’m poking my finger in anyone’s eye but sometimes even this subject can land butter side up as a friend of mine would say.
My wife needed to see an out of network out of state specialist recently. She spent long hours poring through the Humana books, waiting forever on hold till she could talk to a human, yada yada yada, getting multiple conflicting inconsistent answers that mostly said “no, it’s out of network, you’re on your own” before she finally admitted no, they just wouldn’t pay for it from our HMO plan.
So we made the trip and paid out of pocket for the entire consultation fee.
Two weeks later, she was online with her Humana account and just out of curiosity looked at “recent claims” and there was a completed claim from Humana! They paid the entire amount!
Course, we haven’t gotten any refund yet from the provider…
I’m so glad it worked out for you and your wife and sorry she had to spend all that time beforehand with the insurance company. In my case, I purposely choose (for years now) a plan that I can go in network (lower cost) or out of network (higher cost) with a much higher monthly premium than the in network only plan. The reason I keep this plan is in case I do need a specialist not covered in network. What bothers me so is this surprised billing. Granted I had no idea this out of network surgical assistant PA, who I’m certain is not a world renowned specialist, would be doing a service, but that’s a whole other story. The fact that this bill from this mysterious healthcare provider is exorbitant and so much more than the actual surgeon submitted shows the scam it is. Now I have to waste all this time to try to clear this up, and from what I can see, it’s seems like it may be a routine practice that technically the victim (i.e. patient) is totally responsible to pay.
Google “the no surprises act”. The HHS issued some interim rules, but I can’t figure out the effective dates. I think you just missed it. The Biden administration pushed for this.
Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
It was actually “enacted” before Biden…it’s just taking this long for them to figure it out.
“The No Surprises Act was enacted on December 27, 2020 as part of the Consolidated Appropriations Act of 2021. It was generally designed to provide protection from patients being surprised by bills for health care and excessive patient cost-sharing payment obligations. The protection is generally aimed at situations where patients (i) receive care from OON providers who furnish services at in-network facilities, (ii) receive emergency care from OON providers, or (iii) use OON air ambulances.”
I have had a similar situation, where an assisting surgeon was out of network. I refused to pay the out-of-network portion, and they accepted that. This is one situation that can get pretty complicated, and IMO, medical providers have a duty to let us know if they are out of network. Especially in today’s world where things like this can be readily automated thru the hosting facility, usually a hospital.
This two has happed for my wife. She did appeal to the hospital. This appears to be a new game that MD’s are playing… They walk in to surgery or recovery talk to you or your doctor , then bill for a consultation
I do under stand that insurance company are trying to put a stop to this practice.
