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New Insurer Policy and Health Plan Clauses Relating to Fee Forgiveness

I have reviewed a few recent Plan Documents that contain the following wording, “The Covered Person is required to pay the out-of-pocket expenses including Deductbles, Co-pays, or required Plan Parlicipation) under the terms of this Plan. The requirement that You and Your Dependent(s) pay the applicable out-of-pocket expenses may not be waived by a provider under any "fee forgiveness,” "not out-of-pocket," or similar arrangement. If a provider waives the required out-of-pocket expenses, the Covered Person's calm mav be denied and the Covered Person will be responsible for payment of the entire claim. The claim(s) may be reconsidered if the Covered Person provides satisfactory proof that he or she paid the out-of-pocket expenses under the terms of this plan.”

Significantly, if a healthcare provider waives any required out of pocket expenses such as deductibles, coinsurance or even the balance bill, the covered person claims may be denied. Worse, the insurer can retroactively deny the claims once they've been paid sometimes three or four years after the payment. Fortunately, the No Surprise Act does limit patient cost share amounts in some situations for out of network providers. I just wanted everyone on my mailing list to be vigilant about these new clauses. If there are any questions about this or the No Surprise Act, feel free to contact me.

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