Coverage & Consumer Protection

[swjl587]

What is the name of your state (only U.S. law)? California

I recently had to go to the emergency room. The hospital I went to is considered out of network with my insurance provider but I am still supposed to be covered 100% for this. The hospital processed the claim incorrectly and, as a result, my insurance only paid a portion of the entire bill. I am disputing the claim with the hospital and have also reported it to my insurance company. However, it may take several weeks to audit, review and resolve the case.

In the meantime, the hospital will expect payment within 30 days. If it takes longer than 30 days to resolve the situation, is there any type of consumer protection law that would keep me against being reported late on the outstanding balance? I believe things will ultimately be worked out and full payment made by the insurance company to the hospital, but I don't want to get dinged on my credit report for it.

Assistance appreciated.

[cbg]

No, there is no consumer protection law that protects you from being reported late while you are fighting it out with your insurance company.

One thing I think you misunderstand. It would be HIGHLY unusual for a policy to say that in an emergency, an out of network provider will be paid 100% of their charges. What is quite common, and is MUCH more likely, is that it says the out of network carrier will be paid 100% of reasonable and customary charges, which is NOT necessarily 100% of the bill. It is QUITE possible that even if the insurance pays 100% of the R&C charges, you could still end up with a balance due since the insurance carrier cannot prohibit an out of network carrier from charging you the balance. In network providers are required to accept the charges agreed to by the contract with the insurance carrier. Out of network providers are not.

[ecmst12]

In a true emergency, if the policy has 100% coverage, they SHOULD pay an out of network provider at 100% of billed amount. The idea of a network is to encourage patients to choose participating providers. In an emergency, patients should be encouraged to go to the NEAREST hospital and not worry about whether it is in the network or not. When I did customer service, I used to be astounded by people who would call up and say, My child broke his arm, or My husband is bleeding from his eyes, which hospital can I go to? Get off the phone and go to the nearest emergency room, or call 911 if you need to! We'll pay for it, don't worry about it! That was 10 years ago and maybe things have changed, but if so that's a damn shame. If the member is supposed to have 100% coverage, then they shouldn't get a bill just because they did the medically correct thing by going to the closest hospital in a medical emergency.