Spotlight on out-of-network providers in emergency situations

| Jul 3, 2019 | Denied Insurance Claims

A story like the following will never garner positive publicity points for an insurance company. In fact, it will assuredly yield an immediately sharp public response, even without regard for underlying details.

A recent Consumer Reports article highlights the tale of a young girl who was injured while on a skiing vacation. Local hospital authorities made the decision to airlift her to another facility for treatment. The bill for that service was $65,000.

The family’s insurer balked at paying that stunning amount, stating that the air ambulance company was an out-of-network provider and that permission to use its services wasn’t preauthorized. The hospital countered that preauthorization was not required, given the extensive nature of the girl’s injuries.

As noted above, it’s not hard to gauge where public sentiment will reside in such a story. Insurers are frequently painted with a broad brush of condemnation in narratives featuring their questioning of medical charges.

Such questioning often targets truly unexpected medical charges, though, as well as legitimate inquiries into highly ratcheted-up costs charged by some non-network providers. And it is not often that an insurance company becomes embroiled in a story where a failure to pay is linked with a clearly objectifiable emergency. The above article notes, for example, that insurers’ objections are far more often directed to instances of care that is delivered in an arguably non-emergency situation.

Insurance companies logically seek cost controls concerning coverage, just as their policyholders do. Indeed, insurers and insureds have a shared – not a contrastive – interest in striving to keep medical bills logically tied to services rendered. Rules and processes concerning preauthorization, standards for emergency care and network designations all speak directly to the need for mutually beneficial cost containment.

Reportedly, the topic of surprise medical bills is currently a top-tier agenda item for Capitol Hill legislators. Insurers welcome the focus and look forward to lawmaking guidance on the subject matter.