Do Your Employees Think They’re Financially Covered for ER Visits? They May Want to Think Again.

Posted: December 29, 2015 - Benefits Consulting

Digital Benefit Advisors LogoThe Affordable Care Act (ACA) has brought significant changes to the healthcare industry. One of the recently released regulations provides guidance on how ER services are paid; specifically when using out-of-network providers.

What is the difference between an in-network and out-of-network provider?

An in-network provider is one who has agreed with the insurance company to discount their fees for services rendered.

An out-of-network provider is one who is unwilling to discount their fees. As a result, out-of-network providers can charge as much as they want. When members use out-of-network providers, this becomes a problem because the insurance company will generally base their payment on the lower, negotiated fee that an –network provider would have billed.

The difference between what an in-network provider charges versus an out-of-network provider is called balance billing. Balance billing charges are the member’s responsibility and they do not apply to the member’s deductible or out of pocket maximum.

What happens in ER Situations When the Insured Doesn’t Have a Choice?

Under the ACA, it was mandated that out-of-network ER services are to be treated the same as in-network ER services in order to ensure that insureds are not penalized for using out-of-network emergency services. However, ACA did not fix the balance billing issue that could result when using out of network ER providers. As a result, it is important for members to understand if they use an out-of-network emergency room, even in the event of a life threatening situation, the provider may try to balance bill the member.

What should a member do if they find themselves in this situation?

Reach out to your broker’s customer service team. Your broker can help appeal any balance billing charges with the Department of Insurance (DOI). This appeal may take some time and effort and doesn’t always guarantee a favorable outcome.

Your broker can also work directly with the provider to see if they are willing to write off the balance billing charges or to see if the member qualifies for a reduction in charges based on financial need.

Why are we addressing this now if ACA has been in place since 2010?

As the cost of healthcare continues to rise employers and members are looking at leaner networks as a cost-containment strategy. These leaner networks generally ask providers for deeper discounts and as a result, fewer providers join and are considered in-network. As these leaner networks pick up steam, the risk for a member using an out-of-network emergency room facility is greater.

Education is key to help members engage the system and adequately use their health insurance benefits. In addition, having a knowledgeable and hardworking broker who will fight on your behalf is more important than ever.

Elvia Tito

I have over a decade of experience within the insurance industry and truly enjoy building relationships with my clients. My primary goal as an advisor is to become a strategic partner to my clients. I specialize in providing consultative services and assisting my clients with renewal strategies, compliance and industry trends. Digital Benefit Advisors (DBA) delivers a powerful new approach to employee benefits by combining the commitment of experienced, local market advisors with the sophisticated technology and resources of a respected national firm. Our vision is to advance the health and financial well-being of the companies and individuals we serve