BCBS refuse to pay ER visit

My wife had trouble breathing and had a panic attack and my neighbors called for an ambulance. By the time the EMT arrived she had recovered somewhat, but her heart rate was 188 bpm, so they insisted she go to the hospital. It turns out our new plan doesn't include the closest hospital to us. BCBS requested all of her records searching for pre-existing conditions months ago then declined to pay for the reason the cost exceeds the allowed charge. Of course, the hospital isn't on our plan, so... duh! I thought that if the EMT considered her condition an emergency and took her to the nearest hospital, they had to at least treat her immediate distress and then offer to transfer her. This hospital did $8,000 plus of tests! Any advise is welcome and appreciated. -Tim

[Amir Mostafaie]

The new law provides some protection in this ara;

Under the new law, your health plan cannot do the following:
- Require you to get preauthorization for emergency services;
- Make you go through extra administrative hurdles to get your out-of-network emergency services covered;
- Charge you higher copayments or co-insurance for out-of-network emergency services than it charges you for in-network emergency services; and
- Limit its coverage for out-of-network emergency care more than it would limit its coverage if you received care in-network.

Unfortunately, if a health care provider is not in-network, that provider may not accept the plan’s payment rates for a service. He or she may want to bill you the difference between what the plan pays for the service and his or her charge for that service. So, even if the plan has not charged you a higher copayment, you might still get a bill from an out-of-network provider for other charges that were not paid by your health plan. This is called “balance billing.”

Although the new law does not completely solve this problem, it does make some changes that are designed to minimize your bills for emergency care: It sets some standards for what health plans must pay out-of-network emergency providers, and when providers are paid adequately, they are less likely to balance bill.

Your plan must pay the emergency providers the greatest of these three amounts:
1. The amount it pays in-network providers;
2. A payment based on the same methods the plan uses to pay for other out-of-network services (for example, a percentage of usual and customary fees charged by other providers in your area); or
3. The amount Medicare would pay for that service.

Some states have even stronger laws to stop balance billing. You can check with your state insurance department to find out if there are additional laws to protect consumers in your state.

Sincerely,

Amir Mostafaie