Some Tips for Saving Major Bucks When Using Network Emergency Rooms in Illinois with Health Insurance Coverage
Have you ever found yourself with a big emergency room physician bill from Illinois and health insurance coverage from Illinois (individual policy or as an employer group member)? You might find these tips useful for cutting down costs and minimizing financial hardship.
If you don't fit these conditions and/or are not an Illinois resident, disregard the Illinois-specific tips unless you do some good research or receive authoritative advice that the Illinois-specific tip can work for you or not.
If you can see your own doctor in an office visit or go to a network urgent care center, go there. You will save much more using one of these other routes rather than using these tips.
If you don't have either of them available because it's a holiday, late at night, or you risk life, limb, or ability, however, follow these tips for saving possibly big bucks in Illinois with your Illinois insurance coverage (I'm starting this list of tips from square one because some people may not even know the first step to save on the emergency room):
The Federal [Patient Protection and] Affordable Care Act (ACA) requires insurance companies to treat benefits for an Out of Network Emergency Room as a Network Emergency Room. However, the Emergency Room can balance bill the patient, meaning charge the patient more than the insurance company allows Network Emergency Rooms to charge.
The ACA provides some help but always try going to a Network Emergency Room. It's the first step to keeping costs down. The first step to saving money: Prevent balance billing.
If you get better benefits in the Emergency Room compared to the rest of the hospital (non-emergency benefits), stay in the Emergency Room. If you leave the Emergency Room, especially if you end up seeing an Out of Network doctor in the hospital, nothing I say here can help (it can happen, even if it's a network hospital).
This happened to me the first time I went to the Emergency Room on my own as an adult. I only got good benefits paid because I acted like a jerk to the claims representative and wouldn't let them off the phone. Now that I know better, I probably would take it and just sock it away as having done something stupid.
If you can get better benefits outside of the Emergency Room and you can make 100% sure to see a network doctor, go see that doctor. It can cost less than the Emergency Room. If you end up seeing an Out of Network doctor, though, I wash my hands and leave your fate to yourself.
Some policies have really good Emergency Room coverage, though, just require a copay for the Emergency Room. If you have real good coverage like this, just stay in the Emergency Room.
Now for the big tip that can save you big bucks in a Network Emergency Room in Illinois with health insurance coverage that originates in Illinois. Illinois has a law that requires Out of Network "facility-based providers" to NOT BALANCE BILL patients. Long story short, to the patient with health insurance originating in Illinois, it will feel like they're getting billing by a Network doctor. Instead of going after the patient for money in addition to what the insurance company says can be charged, the "facility-based provider" has to negotiate with your insurance company. Illinois law says that they have to leave you, the patient, alone.
Importantly, make sure to understand that Illinois defines a "facility-based provider" as the following type of providers that you see in a Network hospital when you have no choice or control over who you can see (if you had the ability to choose a network provider, this law will not protect you -- but for the most part, you don't have a choice while in the Emergency Room):
As a health insurance agent in Illinois, I've helped some clients save some big money with this law. If you're in the situation that I've described and an Illinois Out of Network "facility-based provider" that you see without choice tries to charge you as an Out of Network provider, point out this law. If they don't believe that such a law exists or they ask you for the text, send them the following link:
http://www.ilga.gov/legislation/publicacts/98/098-0154.htm
They may want to have their legal department look it over, but you've got the law on your side. Their legal department should advise them to suck it up and stop charging you more than what your insurance company allows.
I suggest that you look over the law before sending it over, so you can be familiar with it and discuss it with the doctor's office. I especially suggest doing so because you don't want to invoke the law and send over language that doesn't apply to your situation.
You should not need a lawyer in this situation. If the doctor's billing department and their legal department refuse to relent on the bill after your valid exercise of this law, don't hesitate to go to the Illinois Attorney General Health Care Bureau. This Bureau should advocate and mediate for you with minimal, if any cost, using the powers of the Illinois Attorney General to do so. This very situation is one big reason we have the Attorney General Health Care Bureau.
If you somehow don't find success after tapping the Attorney General's office, it might be time to retain a good lawyer. I can't say they'll bring success, either, but who knows? A good, smart lawyer might be able to perform a miracle. I sincerely hope your travails don't reach this level, especially since you should have Illinois law supporting your position without question.
For people who get Emergency Room services in Illinois but have insurance coverage that originates outside of Illinois, feel free to try working some magic with this law. I can't remember reading anything in the law that requires the insurance coverage to actually originate in Illinois. I've only focused on health insurance that originates in Illinois because I don't have experience, expertise, or insurance licensing for health insurance outside of Illinois. If this law can benefit you, though, it's worth a shot, right? Trying to work it can pretty much just cost you some time, at the worst, and could yield some good savings. Don't take my word as law, though. Again, if you have the choice to use network providers, use network providers.
For anyone who has been victimized in a situation like this, especially in the last year or so, I wouldn't hesitate going back to that Out of Network "facility-based provider" and trying to get some money back or balance dramatically reduced through the power of this law. If you were over charged, you should not have been and the doctor's office broke the law. It's especially important to exercise laws like this because the less it's exercised, the less power it has. Embolden the law now for others in the future.
Good luck!
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