Someone who calls 911 in response to a medical emergency can be unpleasantly surprised when a bill arrives for the cost of the ride and other services provided by emergency medical professionals. A bill for reimbursement can happen even for someone who has health insurance coverage. The legal framework surrounding emergency services is complicated, involving state and federal health care laws and insurance regulations, as well as the often-unpredictable interaction between different service providers.
Federal law requires coverage of emergency services by group insurers, but leaves a gap
The federal Patient Protection and Affordable Care Act (the “ACA”) introduced important changes to how insurers treat emergency services. Under Section 10101 of the ACA, group health plans are required to cover emergency services without pre-authorization from the insurer, and without regard to whether the service provider is a participating vendor under the plan. The insurer is required to compensate the provider at the same level as in-network providers.
Although the ACA protects patients in group insurance plans from paying the full bill for things like ambulance rides, the patient can still be billed for the gap between the ambulance company’s rate and the insurer’s in-network rate, which typically is lower than the “market” rate. So-called “balance billing” is a common source of complaints not just for ambulance rides but also for hospital care. The complexity of the ambulance business further muddies the math, because providers are often free to decide for themselves how to charge for their services and can potentially pile up numerous fees for short rides.
Nevada is still grappling with how to regulate balance billing within the state
Patient advocacy groups have been pushing for adoption of legislation around the country to address unfair balance billing practices, as well as surprise billing (where a patient receiving care at an in-network hospital is charged for out-of-network services provided to the hospital by an outside service). Thus far Nevada has not taken steps to close the gap left open by the ACA. Because the ACA itself is a controversial law that may be changed or repealed, the outlook is unclear as to whether balance billing practices will come under tighter control.
For patients who are faced with a huge surprise bill there may be several options for contesting it. The types of options that are available may depend on the kind of insurance the individual carries—the insurer may require billing disputes to be handled through mediation or through an insurer-driven process. Or the emergency services provider may have had the patient sign a contract that may limit the patient’s options. An attorney may be able to provide guidance on how to resolve these problems.
Talk to a Las Vegas personal injury law firm about your reimbursement questions
For more than 45 years the law firm of Greenman Goldberg Raby Martinez has helped clients in the Las Vegas area protect their legal rights and recover compensation for personal injuries. If you have questions about how to dispute a large and unexpected bill for medical services, we may be able to help. For a confidential, no-cost attorney consultation, call us today at 702-388-4476, or ask us to call you through our contact page.