It can be a panic-inducing moment.
A few weeks ago, you went to an emergency room that’s in your health plan’s network. You paid your copay, got treated and went home to recover, thinking this episode was over.
But now you get a big bill.
Turns out an orthopedist who read your X-ray (unbeknownst to you) was not in your health plan’s network. If your health plan were to treat that service as being “out-of-network,” you would be responsible to pay a much bigger chunk of the bill – or maybe even the whole thing.
Fortunately, Arkansas Blue Cross and Blue Shield and its affiliates (and now federal law) have protections in place to help eliminate potential unexpected shocks to your bank account.
For many decades now, Arkansas Blue Cross and its affiliates have contractually required participating providers (those who are part of any of our networks) to accept the “allowable” charges listed in our fee schedule as payment in full.
Providers in any of our networks are contractually prohibited from engaging in “balance billing” our members.
For example, if a provider charges $500 for a service, but our “allowable” charge is $300, once the member pays required copays, coinsurance and deductibles, the provider cannot pursue the client to pay the remaining difference.
That’s why it is important to wait for healthcare claims to be fully processed before you pay any bill you may receive from a healthcare provider. If you pay bills from healthcare providers as soon as you get them, there’s a very good chance you’ll overpay.
It’s best to wait until you check the explanation of benefits document (provided by your health plan) for the services you received. An explanation of benefits breaks down what was charged and what was paid for each claim that we process.
If you are responsible to pay an additional amount (copay, deductible, coinsurance, etc.), it will be clearly listed on the explanation of benefits.
But beyond this longtime protection, there’s a new law (the Consolidated Appropriations Act of 2021) that specifically calls out situations like an out-of-network orthopedist providing a service at an in-network emergency room.
The law protects you from “surprise” bills for:
• Emergency services – If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider
or facility may bill you is your plan’s in-network cost-sharing amount (copays, deductibles, coinsurance, etc.). This includes services you may get after you’re in stable condition, unless you waive your surprise billing protections in writing.
• Certain services at an in-network hospital or ambulatory surgical center – Claims for services provided at an in-network hospital or ambulatory surgical center (for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology and services by assistant surgeons, hospitalists, and intensivists) must be processed at the in-network rate, even if one or more providers involved in your care is not in your health plan’s network.
Again, the most you must pay is your plan’s in-network cost-sharing amount. And for these services, you can never be asked to waive your protections.
These provisions can help ensure that you get the most value from your health plan and avoid paying more than is appropriate out of your own pocket.
If you need help dealing with a suspected surprise billing issue, simply call the customer service phone number on the back of your health plan member ID card, and we’ll help you get it sorted out.