Hi all,
I have a member who is enrolled in ACA plan in NC.
The member's plan has $0 deductible with $8,550 OOPM.
For ER care, its copay is $1,000 for both in-network and out of network without any limitation.
The member went to ER that was out of network and the provider charged about $9,000 and the member obviously was expecting to pay around $1,000 which is the amount showing on SOB.
However, the insurance company only paid $1,500 and their representatives told me and the member that the member is only responsible for $1,000. I called the provider and was told that since the insurance company is out of network provider, they won't make any adjustment to the bill and the member needs to pay the balance which is around $7,500. I called the insurance company again and was told that the member is responsible for the $1,000 PLUS they could be billed for anything above the allowed amount since it is out of network. Since the member went to an out of network facility for ER, they apply 'Usual and Customary rates' to the billed amount and apply the benefits to this. Anything billed above this is not eligible for consideration to be paid, and the provider can balance bill the member. The member has an option to appeal the rate applied to the bill they said.
As I explained above, the SOB clearly states ER copay is $1,000 for both in network & out of network without any limitation. Of course, I'll advise the member to appeal the rate but if the appeal is denied, what other option does the member have?
Any idea would be greatly appreciated!!
I have a member who is enrolled in ACA plan in NC.
The member's plan has $0 deductible with $8,550 OOPM.
For ER care, its copay is $1,000 for both in-network and out of network without any limitation.
The member went to ER that was out of network and the provider charged about $9,000 and the member obviously was expecting to pay around $1,000 which is the amount showing on SOB.
However, the insurance company only paid $1,500 and their representatives told me and the member that the member is only responsible for $1,000. I called the provider and was told that since the insurance company is out of network provider, they won't make any adjustment to the bill and the member needs to pay the balance which is around $7,500. I called the insurance company again and was told that the member is responsible for the $1,000 PLUS they could be billed for anything above the allowed amount since it is out of network. Since the member went to an out of network facility for ER, they apply 'Usual and Customary rates' to the billed amount and apply the benefits to this. Anything billed above this is not eligible for consideration to be paid, and the provider can balance bill the member. The member has an option to appeal the rate applied to the bill they said.
As I explained above, the SOB clearly states ER copay is $1,000 for both in network & out of network without any limitation. Of course, I'll advise the member to appeal the rate but if the appeal is denied, what other option does the member have?
Any idea would be greatly appreciated!!
