A hospital ER charges an ‘after-hours’ fee. Who has to pay it?

This week, I responded to readers who were unhappy with their health plan's decision not to pay an emergency department surcharge for after-hours care and concerned about difficulties getting Medicare to cover claims unrelated to a workers' compensation injury. Another reader asked about a recently announced hardship exemption from the requirement to have health insurance.

Q: I visited a local emergency room one night after I had a severe allergic reaction that caused intense itching, hives, swelling and blistering. Now I received an "explanation of benefits" notice from my insurer that I will be billed by the in-network hospital for "after-hours" service. My insurer does not cover that charge. I am so enraged. Is there anything I can do to get the hospital to remove the charge?

Tacking on an after-hours surcharge to an emergency department bill strikes some consumers as unfair, since the facilities are open 24 hours a day.

The practice is "pretty rare" but defensible, said Dr. Paul Kivela, an emergency physician in Napa, Calif., who is president of the American College of Emergency Physicians. He noted that the cost to staff an emergency department at night is higher than by day. The surcharge is typically modest, often less than $100, experts say.

But that's neither here nor there. The extra charge should have been built into the overall rate, said Betsy Imholz, special projects director for Consumers Union, an advocacy group. "It's infuriating," she said. "I don't blame [the patient] for being annoyed."

Just because your health plan is balking now at paying the surcharge, that may not be the final word. Hospitals and insurers frequently sort out these surcharges between themselves, without holding patients responsible, said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an industry group.

"If it's an in-network provider, an insurer is generally responsible for addressing the billing of that code under its negotiated contract with the providers," Gundling said.

Medicare beneficiaries are not responsible for paying the surcharge.

If the hospital pursues the patient to pay the charge, Imholz recommended that consumers file an appeal with their health plan, noting that appeals on many issues are frequently successful.

Q: I fell in 2015 and my injuries are being covered by the workers' compensation program. It pays only the claims that are related to my back and neck injuries. But Medicare has been refusing all the claims it receives, including a hospital stay for an acute asthma attack as well as routine visits to my primary care physician. The program states that these claims are the responsibility of workers' comp. What can I do?

Your workers' compensation insurer is the "primary payer" for medical bills that are related to your work-related injury. Medicare is responsible for your other medical care.

Without more information, it's impossible to know exactly why Medicare is denying your claims for medical care that's not related to your work injury.

However, the problem may be rooted in the mandatory data-reporting requirements that the federal Centers for Medicare & Medicaid Services put in place about a decade ago, said Darrell Brown, an executive vice president and chief claims officer at Sedgwick Claims Management Services.

Under the federal rules, insurers and plan administrators have to report claims data about Medicare beneficiaries who are also covered by a group health plan or who receive payments under workers' compensation, among other things. The aim is to ensure that the Medicare program isn't acting as a primary payer on some claims when another health plan or program should be doing so.

"My guess is that there's something that went wrong with that reporting," Brown said. "There's so much data that they're getting, and there's so much room for error as well."

Start by contacting the number or person on the notice you received from the Medicare program denying your claim, Brown said. You may also have to contact the workers' compensation carrier. But your first step should be to find out why the Medicare program mistakenly believes that your asthma hospitalization and other care is related to your workers' comp injury.

Q: Why is there a new exemption from the penalty for not having health insurance if you live in a bare county with no marketplace insurers? There aren't any of those and next year there's no penalty, so what's the point?

As you note, starting next year, people will no longer owe a penalty for not meeting the Affordable Care Act's requirement of having health insurance.

People will, however, be able to apply to the marketplace for a hardship exemption if they live somewhere where there are no marketplace insurers. That may give them another option for coverage.

People who qualify for a hardship or affordability exemption can receive an "exemption certificate number," often referred to as an ECN, which will allow them to buy a catastrophic plan that meets health law standards and is typically available only to people under age 30, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities.

These ACA-compliant plans may be purchased off the exchange, even if no insurers are selling marketplace plans in a particular area.

Catastrophic plans cover the essential health benefits. They often have lower premiums than plans on the health law's marketplace, but their deductibles are comparatively very high and people can't receive premium tax credits to pay for them. The high out-of-pocket costs may explain why they haven't been popular. Fewer than 1 percent of marketplace enrollees picked one in 2018.

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