facility charges and the ACA

[Stellar Clouds]

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Perhaps this could be in a different forum, but I trust the opinions of a lot of the attendings/residents/students here. I recently underwent an ambulatory surgery. My insurance is as follows:

Facility charges:
In-network: co-pay $100, insurance covers 100%
Out-of-network: co-pay $100, insurance covers 70%

My surgeon and anesthesiologist were in-network, but the facility was out-of-network. Because of this, I figured I would owe my co-payment plus 30% of the facility fee. However, when the facility called me prior to my surgery, they said that although I am out-of-network, because of the Affordable Care Act, I would be treated as if I am in-network. Has anyone heard of this being true? Or am I going to be surprised with a bill for 30% of the facility fees in a few weeks?

 

[deleted126335]

Perhaps this could be in a different forum, but I trust the opinions of a lot of the attendings/residents/students here. I recently underwent an ambulatory surgery. My insurance is as follows:

Facility charges:
In-network: co-pay $100, insurance covers 100%
Out-of-network: co-pay $100, insurance covers 70%

My surgeon and anesthesiologist were in-network, but the facility was out-of-network. Because of this, I figured I would owe my co-payment plus 30% of the facility fee. However, when the facility called me prior to my surgery, they said that although I am out-of-network, because of the Affordable Care Act, I would be treated as if I am in-network. Has anyone heard of this being true? Or am I going to be surprised with a bill for 30% of the facility fees in a few weeks?

I am not certain, but you may be in for a horrific surprise when you get your bill. PPOs typically pay 70% out of network of the UCR (usual customary reimbursement) for folks that they have agreements with. These are typically about 40% of charges. Thinking worst case you may get stuck for not only 30% of the UCR, but the balance of their charges
since they have no contract with your insurance company. Not sure what you can do about it at this point.

 

[climbingak]

At our ASC we will often match people's in network benefits. So if someone in network benefits are 80/20 after deductible and out of network is 60/40, we will take the 60% from the insurance, 20% from the patient, and write off 20%. As far as I know this has nothing to do with the ACA. We just do it to allow out of network patients to come to our facility without penalty. When you are non par with an insurance company, you can do whatever arrangement because you don't have a contract. If we wanted we could write off all 40%.

As usual, you should always get the agreement in writing. We write it up for the patient because theyve been through this insurance mess before and know there is a chance they can't believe what we tell them.