I agree with eskimospy on this one. Every insurance plan that I've ever had has been structured so that I am only responsible for the co-pay for in-network care. The entire point of provider networks is that that the providers agree to accept only the allowable amount as payment.
I agree with eskimospy on this one. Every insurance plan that I've ever had has been structured so that I am only responsible for the co-pay for in-network care. The entire point of provider networks is that that the providers agree to accept only the allowable amount as payment.
So Atnea has reformed. Again, insurers do not have to cover balance bills for emergency services.
You started this god damned argument by saying Dave's story was unlikely blah blah blah blah. Its not fucking unlikely. In reality a lot insurers(Atnea preivously, when I had them)/insurance plans only cover up to the out of network allowable amount as defined by the new healthcare law.
You are the one that makes the grand statements that Daves situation is rare/hes full of BS, etc.
Again you were wrong. Its fucking common, I even googled that for you. Its the opposite of what you stated. You kept telling me I was wrong. There are tens of thousands of articles about emergency out of network horror stories. You come in this thread and say its BS/rare. Its anything but. This is why balance billing is an issue. This is why states are slowly trying to make it illegal. Its an issue, its very real and it is not exactly rare. The problem is even more compounded because most don't know their policies and do not get transferred to an in-network provider.
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At least we're finally getting somewhere.
Furthermore, a quick check of Florida law shows that this sort of thing is EXPLICITLY prohibited in Florida, the very place Dave claimed his accident happened.
Dave was full of shit, as usual. Are you done now?
That Florida law only applies to HMOs and not PPOs. And just reading everything Dave has posted over the years points to him having a PPO and not a HMO. Either that or he over stayed in an out of network facility, which is all to common for people receiving emergency treatment in an out of network facility.
Heres a nice little link about balance billing. Notice the vast number of no's in the out of network columns.
http://www.statehealthfacts.org/comparereport.jsp?rep=66&cat=7&rgnhl=11#notes-1
So to sum up
Balance billing in expressly prohibited by in network providers, that even applies to out of network providers in a in-network facility in most states.
Completely out of network(out of network facility and provider) balance billing for emergency services is illegal in 9 states. Some insurance policies will cover balance bills. Some don't. Historically a lot haven't.
Dave's situation is not RARE, unfortunately it is all to common. That is why there have been roughly two decades of debate on the issue. That is why 9 states have banned or severely restricted the practice. Half of them since ACA.
And again, this is it is a good idea for people to have have separate medical emergency/medical evac plans.
Its also a good a idea for people to understand that their policy doesn't cover care after the emergency is over and they are stable but still in the hospital. Unfortunately most don't understand that.
But again balance billing is still alive and well for A LOT of out of network emergency care and will be unless it gets banned under federal law but that is highly unlikely.
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sactoking
Diamond Member
- Sep 24, 2007
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Actually, if you want to be precise (and I do love precision), you're both right and you're both wrong and you can't agree because you're talking about two different scenarios.
Originally the conversation regarded in-network versus out-of-network emergency billing. Someone stated that out-of-network was considered in-network if it was an emergency and there was no in-network provider in the area. The other person countered that that was not true and used balance billing to prove it.
The original statement was correct: someone taken to an out-of-network provider on an emergency basis when no in-network provider is available will have the claim paid as in-network. But this comes with a caveat that this is only true for the deductible and copay/coinsurance.
The rebuttal statement was also correct: someone taken to an out-of-network provider, even on an emergency basis, will likely be subject to balance billing. This is because the in-network/out-of-network and balance billing portions of the policy are distinct and separate.
Most (all?) states require emergency services to be covered at the in-network rate if no in-network provider is available. If the was not true then someone traveling out of state would likely be at a severe disadvantage if an emergency occurred. However, except in those states that have legislatively prohibited balance billing, there is no policy provision that bars balance billing under any circumstance.
Instead, the insurers negotiate the balance billing in to their contract with the medical provider. This makes sense, as balance billing is not an insurer/insured relationship but an insurer/provider relationship. Insurers know that if they allow their in-network providers to balance bill they will get creamed in the marketplace, so they remove that ability in the network contract.
An out-of-network provider, even an emergency provider, has no contract with the insurer (duh, that's why it is out-of-network). Without a contract there is no prohibition on balance billing.
So, while state law and the insurance contracts dictate that the out-of-network provider must be treated as in-network as it pertains to the insurer's treatment of the insured (deductible and copay/coinsurance) there is nothing that dictates that the provider must treat the out-of-network patient as in-network (balance billing).
So there you have it, you're both right and you're both wrong.
Pray To Jesus
Diamond Member
- Mar 14, 2011
- 3,622
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QQ moar .
They can do WTF they want as long as it's legal to do so.
Your choice to eat there or not.
Originally Posted by eskimospy 
At least we're finally getting somewhere.
Furthermore, a quick check of Florida law shows that this sort of thing is EXPLICITLY prohibited in Florida, the very place Dave claimed his accident happened.
Dave was full of shit, as usual. Are you done now?
As Usual I get caught up in some crap I have no idea is coming.
Yes it is a PPO through where I work.
We did not stay. As soon as the people in the ER finished checking each of us out and nothing more they could do were were discharged. debi was first. She then came down to my ER room. They had her in ER Room 4 and me in the last room number 20. They actually wanted to have me stay overnight for observation but we said no to that. I had broken ribs just like debi and they didn't suggest she stay overnight. The main part that cranked the ER bills up was each getting a cat scan, they charged $20,000 for each.
Bottom line is insurance covered $9,000 and I have bills over $40,000 that the Hospital and Insurance says that I am responsible for.
At least we're finally getting somewhere.
Furthermore, a quick check of Florida law shows that this sort of thing is EXPLICITLY prohibited in Florida, the very place Dave claimed his accident happened.
Dave was full of shit, as usual. Are you done now?
As Usual I get caught up in some crap I have no idea is coming.
Yes it is a PPO through where I work.
We did not stay. As soon as the people in the ER finished checking each of us out and nothing more they could do were were discharged. debi was first. She then came down to my ER room. They had her in ER Room 4 and me in the last room number 20. They actually wanted to have me stay overnight for observation but we said no to that. I had broken ribs just like debi and they didn't suggest she stay overnight. The main part that cranked the ER bills up was each getting a cat scan, they charged $20,000 for each.
Bottom line is insurance covered $9,000 and I have bills over $40,000 that the Hospital and Insurance says that I am responsible for.
- Oct 30, 2000
- 42,589
- 5
- 0
ch33zw1z
Lifer
- Nov 4, 2004
- 39,743
- 20,309
- 146
GuitarDaddy
Lifer
- Nov 9, 2004
- 11,465
- 1
- 0
Dennys is an abomination, they represent everything that is wrong with corporate America. They hate their employees and their customers, while they belly up to the trough and gorge themselves on corporate welfare, they force their employees to survive on government handouts and poison their customers.
buckshot24
Diamond Member
- Nov 3, 2009
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ch33zw1z
Lifer
- Nov 4, 2004
- 39,743
- 20,309
- 146
buckshot24
Diamond Member
- Nov 3, 2009
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ch33zw1z
Lifer
- Nov 4, 2004
- 39,743
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buckshot24
Diamond Member
- Nov 3, 2009
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ch33zw1z
Lifer
- Nov 4, 2004
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lol...not much better. The few times I've eaten at Denny's have been underwhelming to say the least.
buckshot24
Diamond Member
- Nov 3, 2009
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ch33zw1z
Lifer
- Nov 4, 2004
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zinfamous
No Lifer
- Jul 12, 2006
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zinfamous
No Lifer
- Jul 12, 2006
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buckshot24
Diamond Member
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werepossum
Elite Member
- Jul 10, 2006
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LOL
One big difference - employers pay for health insurance with pre-tax dollars, you pay with after-tax dollars.
Interesting - you're one of the few people who can see the advantages and the disadvantages.
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