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Balance Billing: What are our rights in Arizona?

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Latest post Fri, May 8 2009 1:55 AM by thnx4help. 2 replies.
  • Fri, May 8 2009 12:14 AM

    Balance Billing: What are our rights in Arizona?

    Hi everyone.

    We live in Arizona.  &n... have an employer assisted health insurance through a large, well known insurance company.   In my plan, the insurance generally only covers service by "in-network" providers, except for emergencies.   Of course, all our normal appointment based services come from in-network doctors and other providers.

    Unfortunately, recently I hat to take my wife, who's covered under my insurance, to the emergency room at our local hospital, because she was in a lot of pain and was vomiting.   The hospital, after examination by the ER doctor and ultrasound, immediately admitted her, saying she needed surgery to remove her gall bladder.   (She had her surgery and has recovered well thankfully.)  The local hospital was in our insurance company's "in-network" list.

    After her discharge from the hospital, we were sent a copy of the claim by the surgeon who was not "in-network" with our insurer.   The surgeon isn't employed by the hospital.&nbs... Initially, our insurance company rejected the bill, because he's "out-of-network".&nbsp... So, I called the insurance company, reminded them that this was an emergency, and that we had no choice as to which surgeon would operate in the hospital.   So, the insurance company paid the claim, but at their reduced "customary and reasonable" rate.   Then, we got a bill from the surgeon saying unless the insurance pays the difference between what he claimed and what they paid, we have to pay the difference.  If we don't pay the difference by some specified date, we will be referred to some collection agency.   Of course, the difference is substantial, in the thousands of dollars.

    I do some online search, and find this practice is known as "balance billing".   Most articles I came across say the practice is illegal in many if not most states, but I can't figure out whether the practice is legal in Arizona.  So, what are our rights in Arizona?   Can the surgeon make us pay the difference?

    What's really frustrating is that if the hospital had picked an "in-network" surgeon, they'd have accepted the contracted rates, and we'd never have this hassle.   It's bad enough when you go through a serious medical emergency, but then having to be caught in a run-around between doctors and insurance companies is just a nightmare.

    I would much appreciate any insight anyone who's familiar with this area can provide us.

    Thanks very much.




  • Fri, May 8 2009 12:54 AM In reply to

    Re: Balance Billing: What are our rights in Arizona?

    The problem is that the out-of-network surgeon has no contract with your insurance company and thus is not obligated to accept the insurance company's "customary and usual" rate. Insurance companies set these rates too low, and you end up having to fight the insurance company (with whom you have a contract) to get this paid.

    While some states, notably CA, do have rules that provide protection from this situation, it is my understanding that many do not. Whether AZ does, I don't know. You might start by asking the AZ state insurance regulator—they would likely know the rules that apply to health insurance practices in your state.

  • Fri, May 8 2009 1:55 AM In reply to

    Re: Balance Billing: What are our rights in Arizona?

    Thanks, Taxagent.   I'll see what I can find out from the AZ insurance regulator.  ... Would it be the same regulator that has jurisdiction over the surgeon?   Or would that be some other state agency (eg the medical licesing board etc.)?

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