Anesthesiologist is billing $3700 even though insurance is telling them to stop.

[u/JulesSherlock]

My husband went to the emergency room due to food blocking esophagus. He had to have a gastroenterologist, push it on down. The anesthesiologist billed his insurance who refused it based on it being filed too late. Procedure was 3/8 and they billed 7/1. Then they billed him $3700, which is when he noticed the issue. Said insurance paid $0 and if he didn’t pay by 9/15 it would go to collections. He called his insurance (United Healthcare - Medicare) and they said they would call them the next day and have them refile it. He watched for it online and saw that it had been re-filed on 8/1 so he thought it was ok. Well, insurance denied it again. It says denied due to filing too late and do not bill member. Same as last time. So he expects to get a bill in the mail any day now.

I feel like we’re going in circles. How do we get off this ride if we do get the bill again?

[u/Long-Raccoon2131]

First is the provider in network? If not they aren't obligated by a contract with the health plan to not bill. Also at the ER did you fill put forms one of which thet call patient responsibility form? That form ks a legal document stating you agree to pay anything not covered by insurance. Now is Medicare the only plan? Because if there is a primary policy and Medicare is secondary then primary deductible and out of pocket trump secondary billing

[u/Fin-Tech → u/Long-Raccoon2131]

What about the No Surprises Act? I'm thinking if the ER was in-network but the anesthesiologist wasn't, then the advantage plan is required to pay and the anesthesiologist is prohibited from balance billing under the NSA. Am I mistaken?

[u/Long-Raccoon2131 → u/Fin-Tech]

That ACT doesnt mean what many think it means. It means you cant be surprised with a bill ypu acknowledge and consented to. The No Surprises act is for when you cant make a decision and are air lifted or sent by ambulance to a non participating network hospital. If you went there yourself you signed cornet forms and patient responsibility forms.

[u/AgreeableCoconut2037 → u/Long-Raccoon2131]

This is completely incorrect. Not only does the No Surprises Act mandate in-network coverage for emergency services at OON facilities (regardless if you choose the ER yourself or if you arrive via ambulance), it specifically bans balance billing for OON ancillary services like anesthesiology when services are not emergency services but are rendered at an in-network facility.

[u/Fin-Tech → u/Long-Raccoon2131]

Below is an excerpt from: https://www.cms.gov/medical-bill-rights/know-your-rights/using-insurance#emergency-room-care

If your health insurance covers emergency care, you can't be charged any more for emergency medical services than the in-network “cost-sharing” rate by:

The hospital
The providers giving you care at the hospital
Your air ambulance provider (if you were taken to the hospital in an air ambulance)

<end excerpt>

OP's anesthesiologist was a "provider giving you care" and so the NSA would apply according to CMS.

Regarding your point about "can't make a decision," I would argue that a choking patient in the ER does not have effective agency to make any kind of "decision" (much less an informed one) about which anesthesiologist to use if there was even more than one option in the first place. I feel like this lack of transparency and agency is a foundational reason why the NSA was needed in the first place.

[u/miragud → u/Long-Raccoon2131]

Totally wrong. No idea where you came up with that. Completely ridiculous.

[u/cuspeedrxi → u/Long-Raccoon2131]

This is the correct answer. Disregard the one-liners about ignoring the bill. You need to determine if the physician is in-network and if you agreed to pay for charges not covered by insurance.

[u/Ridgewoodgal → u/cuspeedrxi]

This is odd since almost everyone else is saying if in-network that it is not the patient’s responsibility. Don’t we always sign a form like that but it isn’t for mistakes made by an in-network hospital.

[u/cuspeedrxi → u/Ridgewoodgal]

It’s two separate considerations. 1) Is the doctor in-network? If so, he’s bound by the contract he signed with the insurer. If he filed the claim outside of the required window, then you’re off the hook. It’s his error. Though you may need to remind him of that. Don’t just ignore the bill. Circle back and explain why you’re not liable for the bill. 2) Did you sign a patient responsibility form? If he’s out of network, then you have to pay whatever he charges. But, what else does this form say? Any surprises??

Too often people on these subs advise you to “screw ‘em” and leave it at that. Then, bills get turned over to collections and people have a bigger mess of their hands because they ignored the bill or didn’t follow up, etc.

[u/bethaliz6894 → u/cuspeedrxi]

#3 - Was the insurance card presented in a timely fashion? If they checked in and said we will give the card later and didn't, they can still be on the hook for the bill.

[u/JulesSherlock → u/Long-Raccoon2131]

I think the provider is in network because he had surgery at the same hospital with the same anesthesia provider in January and insurance did pay that bill.

Medicare advantage is the only insurance.

I do not know about the patient responsibility form.

[u/wistah978 → u/JulesSherlock]

Contracts change. It is likely but not certain that they were still in network. Check your insurance website for the provider's status.

[u/OkLime225 → u/JulesSherlock]

It would say out of network on the bill and in the patient column it would have the full amount. Sounds in network and you are not responsible

[u/JulesSherlock → u/OkLime225]

Nothing on EOB or bill says out of network. And EOB states his portion as $0.

[u/JKTX30 → u/Long-Raccoon2131]

If it is an emergency, they cannot trick you with hidden "patient responsibility" clauses in the fine print anymore, thanks to the No Surprises Act, whether it is in or out of network. (Of course, you are still responsible for any deductibles and copays that maybe applicable, but emergency care is covered at the in-network benefit level.)

[u/Long-Raccoon2131 → u/JKTX30]

Emergency means you could not be of sound mind to make a decision therefore whatever treatment is protected by that ACT. If you go on your own free will even if you called for the ambulance you on your own volition enacted the request and it was up to you to understand your plan. Also not all insurance is covered under that ACT either only Medicare specifically and if a states medicaid chooses to. Most marketplace ACA plains abide by it. Yet employer insurance or private bought it does not protect it. EMERGENCY doesnt mean you went to the ER for anything it means you went and had no knowledge of it and you were sent without you asking. This is mostly about air transportation or major accidents where you are unresponsive and they send you wherever

[u/JKTX30 → u/Long-Raccoon2131]

This is incorrect. The standard of an emergency is the reasonable person standard that someone would reasonably believe they are in danger of death or serious impairment of some kind if they do not seek immediate treatment. And the act covers going to any emergency room in that case, whether by car or ambulance or whatever. And the act also covers most all common types of health insurance plans. You can read all the details here and the no surprises act is in fact pretty broad in its protections against surprise billing in emergency (and even some non-emergency) situations. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/avoid-surprise-healthcare-expenses