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New California Law Protects Patients from Surprise Medical Bills

Even when patients take steps to verify that their medical care will be covered by insurance, many are still hit with surprise medical bills. Thankfully, a new California law will help protect patients from unexpected bills from out‐of‐network providers.

Surprise Medical Bills

Nearly one in four privately insured California patients was hit with a surprise medical bill in which their health insurance covered less than expected, according to a 2015 survey conducted by the Consumer Reports’ National Research Center. The same percentage of respondents reported being charged at an out-of-network rate when they believed a provider was in their network.

Surprise medicals bills often involve services provided by pathologists, radiologists, anesthesiologists, and assistant surgeons. In many cases, patients have no choice in selecting their provider, but, rather, are treated by whoever is working a particular shift. For instance, a patient may verify that the hospital and surgeon performing his knee replacement are in network, only to discover after the procedure that the anesthesiologist was outside of his insurance network.

New Requirements Under Assembly Bill No. 72

A new California law, Assembly Bill No. 72, aims to reduce surprise medical bills. It establishes a payment rate for reimbursement of out-of-network doctors, which is the greater of the average of the health insurer’s contracted rate or 125% of the amount Medicare reimburses for the same or similar services.

The law further provides that if a patient receives covered services at a contracting health facility and receives care provided by a noncontracting individual health professional, the patient will be required to pay only the same cost sharing required if the services were provided by a contracting individual health professional. In other words, if being treated at an in-network facility, patients are only accountable for the in-network share of the cost, even if the care is provided by an out-of-network provider.

The new requirement applies to non-emergency services received on or after July 1, 2017. Covered plans include private health insurance plans that fall under the oversight of the state Department of Managed Health Care (DMHC) and the state Department of Insurance.

As San Diego injury lawyers, we are pleased that this much-needed healthcare reform has become a reality. When recovering from a serious accident or illness, unexpected medical expenses can add to the stress of the situation. We encourage patients to carefully review their medical bills and question any charges that do not appear to be accurate.

If you or someone you love has been seriously injured due to someone else’s negligence, don’t hesitate to contact a San Diego personal injury lawyer at the Law Offices of Robert Vaage for a free consultation.