California Assembly Bill (AB) 72 – Member Cost Sharing for out of network services

Effective July 1, 2017 insured members will be protected from “surprise or balance” bills from out of network doctors when receiving non-emergency care at an in-network facility. A common instance of this is when an insured schedules a surgery with a network surgeon at a network surgery center or hospital and a non-contracted anesthesiologist shows up moments before the surgery. This historically has left the patient responsible for 100% of the anesthesiologist’s charges in excess of the contracted rate. In 2015 Consumers Union found this type of billing occurred 1 in 4 times!

This law applies to plans approved by the California Department of insurance and the Department of Managed Health Care. This represents virtually all plans sold in the individual and small group market in the State of California.  One warning: the law allows non-network providers to bill you out of network rates, but only if you voluntarily sign a form at least 24 hours BEFORE you receive care.

More than ever consumers need to examine each claim statement they receive. If you see an amount in excess of the allowed charges, do NOT automatically pay it. And for SURE do not pay a bill from an out of network provider until you received an Explanation of Benefits from your insurance company.  Unless you signed the above release, or there is some other extenuating circumstance, you most likely are NOT responsible to pay the excess amount. Given this is a brand new law we have no experience with disputing improperly billed claims. A logical first step is to contact your insurance company and explain the issue. If this does not resolve the issue be sure and call our office.