Time Magazine 
Out of Network Charges
March 2016

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Out of Network Problems

Insure Me Kevin.com on MD’s using bait and switch to mess with the networks 6.18.2016

Pending Legislation to block surprise medical bills 89.3 KPCC  6.20.2016    AB 72 

 Provider Directories

SB 137  Insurance Code §10133.15  Effective 7.1.2016

  • Health plans must update their printed directories at least every quarter and their online directories at least every week if providers report changes.
  • Provider directories must be posted online and be available to anyone, not just enrollees. Print directories must be available upon request.
  • The directories must “prominently” display directions for consumers who want to report inaccuracies. Upon receiving complaints, plans have 30 business days to makes changes, if necessary.
  • Providers must inform plans within five business days if they are no longer accepting new patients — or, alternately, if they will start accepting them.
  • Health plans can delay payments to providers who fail to respond to attempts to verify information.

The law also gives consumers recourse. Let’s say you use a provider directory to find a doctor but you’re billed the out-of-network price because the directory was wrong. In that case, health plans must reimburse you the amount beyond what you would have paid to see an in-network doctor. CA Health Line 8.26.2016

Bay Area – Blue Cross – virtually no providers – Insure Me Kevin.com 8.25.2016


Out of Network Provider

The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverage’s can go out-of-network, but will pay some additional costs.  Learn More ==>  Specimen Policy Definition page 168 

Negotiated Fee Rate
Maximum Allowed Amount 

is the amount of payment that an Insurance Company has negotiated with the Participating Provider as the maximum they can charge  Page 42 Blue Cross EOC  & 167   More explanation calhealth.net– Can MD’s charge more? Uninsured?

Definition Out of Pocket Maximum

Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.out-of-pocket maximum. This means that once your expenses reach a certain amount in a given calendar year, the reasonable and customary fee for covered benefits will be paid in full by the insurer.   Specimen Policy Page 5      56   Learn More ===> Our webpage

United Health Care Webpage explaining Payment on Out of Network Benefits for certain plans.

The terms “the reasonable and customary amount,” “the usual, customary, and reasonable amount,” and “the prevailing rate” are among the standards that various health care benefit plans may use to pay out-of-network benefits.

FAIR Health provides health care consumers with an estimate of how much out-of-network services will cost them. Health care consumers can access FAIR Health’s Consumer Price Lookup at:  http://fairhealthconsumer.org/.

ER Balance Billing

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