This week, I taken care of immediately readers who have been unhappy using their health plan's decision to not pay an emergency department surcharge for after-hours care and worried about difficulties getting Medicare to pay for claims unrelated to a workers' compensation injury. Another reader asked about a recently announced hardship exemption from the requirement to possess medical health insurance.
Q: I visited a nearby er one night after I were built with a severe allergic reaction that caused intense itching, hives, swelling and blistering. Now I received an “explanation of benefits” notice from my insurer which i will be billed through the in-network hospital for “after-hours” service. My insurer doesn't cover that charge. I am so enraged. Is there anything I'm able to do to get the hospital to remove the charge?
Tacking with an after-hours surcharge to an emergency department bill strikes some consumers as unfair, because the facilities are open 24 hours a day.
The practice is “pretty rare” but defensible, said Dr. Paul Kivela, an emergency physician in Napa, Calif., who's president from the American College of Emergency Physicians. He noted that the cost to staff an emergency department at night is greater than by day. The surcharge is typically modest, often less than $100, experts say.
But that's neither here nor there. The extra charge should have been included in the general rate, said Betsy Imholz, special projects director for Consumers Union, an advocacy group. “It's infuriating,” she said. “I don't blame [the patient] for being annoyed.”
Just because your health plan is balking now at paying the surcharge, that may not be the final word. Hospitals and insurers frequently sort out these surcharges between themselves, without holding patients responsible, said Richard Gundling, a senior vice president in the Healthcare Financial Management Association, an industry group.
“If it's an in-network provider, an insurer is usually accountable for addressing the billing of that code under its negotiated contract with the providers,” Gundling said.
Medicare beneficiaries aren't accountable for paying the surcharge.
If a healthcare facility pursues the individual to pay the charge, Imholz recommended that customers file an appeal using their health plan, noting that appeals on many issues are often successful.
Q: I fell in 2021 and my injuries are being covered by the workers' compensation program. It pays just the claims that are associated with my neck and back injuries. But Medicare continues to be refusing all the claims it receives, including a hospital stay for an acute asthma attack as well as routine appointments with my doctor. The program states these claims would be the responsibility of workers' comp. What can I actually do?
Your workers' compensation insurer is the “primary payer” for medical bills that are associated with your work-related injury. Medicare accounts for your other medical care.
Without more details, it's impossible to know precisely why Medicare is denying your claims for medical care that's not related to your projects injury.
However, the issue might be rooted within the mandatory data-reporting requirements that the federal Centers for Medicare & Medicaid Services put in place about a decade ago, said Darrell Brown, an executive v . p . and chief claims officer at Sedgwick Claims Management Services.
Under the government rules, insurers and plan administrators have to report claims data about Medicare beneficiaries who are also covered by an organization health plan or who receive payments under workers' compensation, amongst other things. The goal would be to be sure that the Medicare program isn't acting as a principal payer on some claims when another health plan or program should be doing this.
“My guess is that there's something that went wrong with this reporting,” Brown said. “There's a lot data that they're getting, and there is a lot room for error as well.”
Start by contacting the amount or person around the notice you caused by the Medicare program denying your claim, Brown said. You may even have to contact the workers' compensation carrier. However your initial step ought to be to find out why the Medicare program mistakenly believes that your asthma hospitalization along with other care is related to your workers' comp injury.
Q: Exactly why is there a new exemption in the penalty because of not having health insurance if you reside inside a bare county with no marketplace insurers? There isn't any of those and next year there's no penalty, so what's the point?
As you note, starting next year, individuals will no more owe a problem because of not meeting the Affordable Care Act's requirement of having medical health insurance.
People will, however, be able to affect industry for any hardship exemption when they live somewhere where there are no marketplace insurers. That may provide them with an alternative choice for coverage.
People who qualify for a hardship or affordability exemption can receive an “exemption certificate number,” often referred to as an ECN, which will permit them to purchase a catastrophic plan that fits health law standards and is typically available only to people under age 30, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities.
These ACA-compliant plans might be purchased from the exchange, even when no insurers can sell marketplace plans inside a particular area.
Catastrophic plans cover the essential health benefits. They frequently have lower premiums than plans on the health law's marketplace, but their deductibles are comparatively high and individuals can't receive premium tax credits to pay for them. The high out-of-pocket costs may explain why they weren't popular. Fewer than 1 % of marketplace enrollees picked one in 2021.