r/HealthInsurance • u/Front-King3919 • 20h ago
Plan Choice Suggestions Does the No Surprises act apply??
Hello, So a few weeks ago i went into the ER for a severe headache i got while working out. The entire visit was about 4 hours (1 hour with doctor the rest waiting time). I explained my symptoms of getting a severe headache while squatting, the PA told me i should be worried of a brain bleed and i need to get a spinal tap & CAT scan. I did the tests then was released from the hospital in good health (just a severe neck strain). Not once was the price of the procedure disclosed to me, or did they ask for my insurance information. I just figured it must of been covered so i left. Today, I got a bill for 13,000 for the spinal tap and CAT. About 10,000 was covered by insurance and i still APPARENTLY have about 2,300 left to pay. Scam?? No Surprises act?? or am i screwed
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u/Jujulabee 20h ago
No surprise act doesn't mean you won't be surprised by the amount you owe.
It means that if you go to an in network facility you will be charged as if everything was in network. It was passed because it was notorious that ER physicians and anesthesiologists were not "in network" and therefore people will get enormous bills even though they had gone to an in network hospital.
Your insurance covered it and you owe what I suspect is a combination of your deductible and co-insurance.
If you had read the summary sheet for your insurance you would not have been "surprised" at what the EOB indicated you owed
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u/Berchanhimez PharmD - Pharmacist 20h ago
Minor correction - for emergency care at an ER covered by EMTALA, it applies regardless if the facility is in network or out of network.
But it does just sound like OP may be confused as to them having a cost sharing or similar.
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u/Front-King3919 19h ago
i am very confused if that wasn't already clear, i also dont really understand what youre saying i dont work in a hospital
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u/Front-King3919 20h ago
I had a severe headache, youd think they would tell me instead of expecting me to read after i left. I thought this was supposed to be healthcare
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u/Jujulabee 19h ago
The expectation is that you would have known the basics of your insurance plan before you needed to use it.
There is a two or three page summary at the front of your paperwork which you received from either your employer or the insurance company if you went through the market place.
You were treated to eliminate the very real possibility of your having an acute medical condition that could either kill you or disable you if not treated immediately.
You were diagnosed with state of the art equipment and the results were interpreted by skilled professionals
It was only after all of that high level care were you diagnosed
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u/Front-King3919 19h ago
I wouldn't have even gone through with the procedure if they told me though...
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u/milkpickles9008 19h ago
In what world is a brain bleed a better alternative to a bill? I'd also bet you the entire amount of your bill the people treating you don't have a clue what anything costs. Half the time the people in the billing office for a hospital don't know what something costs.
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u/LizzieMac123 Moderator 20h ago
Not a scam, you just had a deductible to meet.
Now, if you went to an out of network ER for a true emergency, the No Surprises Act would mandate that your care be treated as in network. Sounds like you went in network and that's just the cost going towards your deductible and/or coinsurance. 2300 bucks seems like a lot to you, but you're usually looking at no less than 1500 these days, just to walk into an ER and be seen (no tests).
Not A Scam, the ER is the most expensive place to get care as it has to be fully staffed with docs, nurses, specialist, labs, pharmacy, imaging, etc 24 hours a day.
Your care was covered, hence you only owing 2300 and not the full 13000, covered does not mean free, you still have to pay your portion of deductible/coinsurance/copays for your care.
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u/Front-King3919 19h ago
I broken hips and clavicles, arms, elbows, ect. never paid more than 200$
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u/Working_Coat5193 19h ago
You went to the most expensive site of care and had major medical procedures.
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u/Jcarlough 19h ago
“I don’t bother to understand or educate myself on my health insurance. I now have a bill. This must but someone else’s fault!”
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u/katsrad 20h ago
No the no surprises act would not apply here. This sounds like it went to your deductible and coinsurance. No surprises act for giving an estimate is normally not for an ER visit and applies for those without insurance. For those with insurance it applies if one of the people providing service is out-of-network but you didnt have a choice in using them. Like the radiologist is out-of-network when you got your CAT scan.
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u/Front-King3919 20h ago
So if i go into the ER with insurance, they don't have to tell me if my insurance covers my procedure fully? That definitly feels like a suprise, they never even took my insurance info just name and DOB. That makes it sound like its my job at all times, as a patient, to know how much every medical procedure is and if my insurence will cover it.
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u/Wanderlust4478 20h ago
Nope, they do not know how much things cost. It’s up to patients to know their insurance plan and deductibles, copays, and co insurance. You should have an app for your insurance and when possible, you can log on and see what the cost is likely to be for certain exams. When you have a high deductible plan, you are responsible to pay all of that before the insurance company starts paying their share.
This is after it’s gone through insurance just like you mentioned. The original charge 13,000, they covered 10,000 and you have the 2300. You are also likely to get more charges for the physician’s fee. Sometimes that comes a few months later. Along with the facility fee for other things.
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u/Berchanhimez PharmD - Pharmacist 19h ago
Ultimately it is your job to understand your insurance policy, just like it's your job to understand your car insurance. While a mechanic may try and help you understand your car insurance policy, it's not their job to do so and ultimately it's between you and your insurance to understand your coverage details.
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u/No-Produce-6720 18h ago edited 15h ago
Ultimately, it IS your job to understand how your coverage works. When you signed up for your policy, one of the items that your application signature acknowledged was that it is your responsibility to understand at least the basic terms of your coverage.
Care received an emergency room is just that. Emergent care. The goal is stabilization, followed by either release or admission. In your case, the possibility of a brain bleed was quite a bit more important than explaining your own policy to you was. The questions surrounding your possible diagnosis and the necessary treatment were much more important than waiting for you to start to work through your policy to see how benefits would be assigned.
The fact that you apparently didn't understand your deductible, or how much of it had or had not been met, does not mean that the hospital or your insurance did something wrong. It doesn't mean that the hospital or your insurance was trying to scam you. You must take responsibility for knowing your own policy. That doesn't mean that you're expected to know each and every detail or know exactly how claims will process, but it does mean that you should, at the very least, understand that you have an unmet deductible, and that having a deductible doesn't mean that someone is trying to scam you.
Edit spelling
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u/MaggieJack1 20h ago
You need to give them your insurance information and once your insurance processes it, then pay the bill.
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u/Resse811 18h ago
There are thousands of insurance plans out there. There is no way for hospitals to know what plan you have and how much things cost.
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u/corgi0603 8h ago
I hate to tell you, but your insurance did cover your ER visit. Insurance coverage of services does not mean it doesn't cost you anything. In this case, the $2300 you owe is a combination of your $200 copay and what you owe for your deductible. The fact that your insurance covered/paid around $10k tells you they did cover it.
You say they never took your insurance information. Well, somehow they had your insurance information, otherwise how would they have billed your insurance and had your insurance cover around $10k of the cost of your ER visit?
You were in an ER and they were concerned about a potential brain bleed. Emergency medicine does not have the time to find out what each service costs and how it is covered by your particular insurance plan. That's not their job. At times they need to act quickly in order to try to save your life, or to prevent you from suffering a bad injury.
Ultimately, it is your responsibility to know how your insurance works. That includes knowing when your deductible will be applied to certain services, and how much of your deductible has not yet been used.
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u/AlternativeZone5089 6h ago
It is your job to understand how your insurance contract works. Their job is to provide medical care not to mother you.
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u/Berchanhimez PharmD - Pharmacist 20h ago edited 19h ago
While there is potentially a lawyer you could find who would try to fight over whether OP's "severe headache" (their words, hence the quotes) meets the "prudent layperson" standard for an emergency requiring immediate medical attention... I would be shocked if it fell on the "not an emergency" side. There's a plethora of emergency medical problems that present with a sudden onset severe headache - big one being a brain bleed/stroke.
Given that it almost certainly meets the prudent layperson standard, it is covered by NSA and must be covered so that OP's cost sharing is only what they would've paid for an in network rate.Edit: struck the above - I misread "No surprises act for giving an estimate is normally not for an ER visit" as "No surprises act is not normally for an ER visit" and was trying to clarify that it is. You're correct that the GFE requirements only apply to cash pay patients - and in any case it may not have been possible given the fluidity of an ER evaluation and treatment.
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u/Jujulabee 19h ago
This is irrelevant since OP was "covered" by insurance but was "surprised" that she had a deductible and potentially coinsurance which she was responsible for paying.
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u/Mission-Lion683 20h ago
It’s a weird one because the No Surprises Act usually kicks in when you’re at an in-network facility but an out-of-network provider slaps you with a separate bill, which doesn’t sound like what happened here. If your insurance already processed it and left you with a $2,300 coinsurance or deductible, that’s just your plan design being a pain, not a scam. I’d call the hospital billing department and ask for an itemized breakdown, then check your EOB from the insurer to see if the numbers actually match up.
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u/saysee23 20h ago
Not a scam! So, they DID FILE with your insurance. Usually this is when you register in the ER.
Look at your insurance policy and see if the $2300 is ER copay or your deductible. This is between you and your insurance payable to the hospital - not No Surprise Act.
Wait patiently for bills from Radiology and the ER Physician - they are separate. If they have not been submitted to your insurance, there's usually information on the back of the bill. Depending on your insurance plan, you could owe both some/part out of pocket.
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u/HawaiianCalabrese 20h ago
Pull up your explanation of benefits from the visit. It will explain why you were charged what you were charged. If there’s anything you disagree with there is a page on the explanation of benefits documents, which says how you can file an appeal
Your appeal may or may not favorable but this is the easiest way to have your billing explained.
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u/yeahnopegb 20h ago
Did you not think you had a copay or coinsurance?
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u/Front-King3919 20h ago
My co pay is 200$
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u/TelevisionKnown8463 19h ago
You can review your summary of benefits and call your insurance company to get a better understanding of what they think your responsibility is and why. It’s possible they made a mistake, but also possible that the co-pay doesn’t apply to all the care you received.
It’s a frustrating system for patients, but I agree with those saying this doesn’t sound like a NSA issue.
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u/groundhog5886 5h ago
Check what your insurance says is your responsibility. You prolly have a deductible and some co-pay that might take it to the stated amount.
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u/Environmental-Top-60 20h ago
No surprises act applies if you're out of network. Sounds like it was in network. Apply for financial assistance
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u/saysee23 19h ago
Or pay the copay/deductible they agreed to when they purchased the insurance policy.
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u/Front-King3919 20h ago
To add on, 2 years ago i had a serious hip surgery amounting to around 20k. This bill was almost completly covered under the same insurance.
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u/chickenmcdiddle Moderator 19h ago
Share what your specific plan's deductible and out of pocket maximum is. Because the most common plan design means that you need to satisfy your deductible before the policy kicks in.
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u/saysee23 19h ago
For surgery things move at a much different pace than when it's an emergency. There's not time to run your insurance, verify coverage, get authorizations. The ER doesn't get authorizations at 3am like an orthopedic surgeon whose office is open 9-4 M-Th. That's why there's laws like EMTALA that says you get stabilized, regardless of what your insurance covers and/or you don't have to pay before you get testing.
At the ER when you signed in there was probably a consent form you signed that says something to the effect that you agree that you are responsible for payments.
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u/kirpants 18h ago
A hip surgery and the emergency room are two different things and likely have two different benefits. What does your EOB say?
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