California Emergency Physicians of America (CEP), and North Tahoe Emergency Physicians (NTEP), the physician groups that provide 24-hour emergency room coverage for Tahoe Forest Hospital and Incline Village Community Hospital, respectively, may or may not be contracted with your health plan.
There are many complicated reasons why emergency room physicians, not only in Truckee, but also across the nation contract with very few health plans. However, the primary reason is the federal Emergency Medical Treatment and Active Labor Act law known as EMTALA, which heavily regulates emergency room physicians.
The EMTALA laws dictates that emergency room physicians have a duty to provide medical assistance to any and all individuals who come to the emergency room seeking care regardless of their insurance or ability to pay. The law, originally developed to prevent discrimination, has had some serious and unanticipated affects on our country's health care providers. The most pressing issue is non-payment or a severely reduced payment by health plans, because the emergency room physician is a non-contracted provider. (For more on EMTALA visit http://www.emtala.com).
As a health plan member you have recourse for non- or reduced payments by your insurance company. Health plans have an appeal process for claims that have been paid. You must contact your health plan and inform them that your service was provided at a contracted facility and that you had no choice as to the physician providing your medical treatment. Remind them that your visit was an emergency and that you did go to a contracted hospital to seek care. Request that the health plan reprocess the claim allowing 100% of the billed charges and that they pay your claim per your plan's emergency medical care benefit structure.
If the initial person you speak to tells you that the physician is not contracted and there is nothing that can be done, ask to speak to a supervisor. Often the first person you speak to is unaware of your plan's emergency medical care benefit structure, due to limited job knowledge.
Another helpful law in having your claim reprocessed is California's Prudent Layperson Standard. Which states if a prudent layperson, a non-medically trained person using reasonable judgment believes that an emergency situation exists, a prior authorization from the member's health plan is not required for the services to be covered.
It is always a good idea to contact your health plan as soon as medically possible to let them know that you or one of your family members sought emergency medical treatment at the nearest medical facility. This should help expedite the processing of your medical claim. Please remember that you are still responsible, as outlined in your health plan benefits, for any deductibles or co-payments that must be met.