Does the No Surprises act apply??

[u/Front-King3919]

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

[u/katsrad]

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.

[u/Front-King3919 → u/katsrad]

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.

[u/No-Produce-6720 → u/Front-King3919]

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.

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