The State of Connecticut Office of the Healthcare Advocate (OHA) hosted its latest Lunch & Learn over Zoom on February 22 with OHA Outreach Coordinator Denise Ramautar sharing information about the organization and what it offers residents.

“The Office of the Healthcare Advocate is an independent state agency. We provide free services to all Connecticut consumers who have any issues with their health insurance. We’ve been serving the people of Connecticut for over 16 years now,” she said.

OHA staff attorney Adam Prizio led the February presentation titled, “The High Costs of Going Out of Network.”

The program highlighted balance billing and how seeing an out-of-network provider can be much more expensive than going to a provider who participates in their health plan.

Prizio explained, “Balance Billing is the difference between the ‘Allowed Amount,’ which is identified or negotiated by a carrier insurer, and the amount that a provider charges.”

For example, he shared that if a doctor charges $200 and the insurance covers less than that $200, the amount remaining is what the consumer is responsible for paying.

“In-network providers, under Connecticut law, are not allowed to bill you for any amount other than a co-pay, co-insurance, deductible, or other cost share as identified by your policy,” his slide detailed.

As for the difference between “Balance Billing” and “Surprise Billing,” Prizio said that he thinks of surprise billing as a subset of balance billing under a particular set of circumstances.

His example is if someone goes to an in-network facility for a procedure and one of the people — an anesthesiologist, radiologist, etc. — is not bound to the contract with the insurance.

“Under Connecticut law … when you are going to an in-network facility and you don’t have a choice, that is a surprise bill and there are some additional consumer protections there,” Prizio said.

In those cases, they must be billed and adjusted as if they were in-network, and the provider cannot balance the bill.

He then shared what that could look like in an extreme case study regarding someone who had frequent appointments with an out-of-network mental health provider, paid out of pocket at the time of treatment, and submitted receipts to the insurance carrier for reimbursement. In the example, the person paid $18,000 annually to their provider but was only reimbursed $2,400 and they did not feel this was well covered.

“You give up a lot of protection when you see an out-of-network provider,” Prizio said.

Another takeaway from the case study was that these scenarios are likely to happen with out-of-network providers who are seen frequently, such as for physical, occupational, or speech therapy or for mental/behavioral health and substance abuse.

“Carriers are required to have an adequate network of providers. They are required under state law to make it so that you don’t have to wait an unreasonable amount of time or travel an unreasonable distance. What’s [considered] unreasonable — there may be some interpretation there,” Prizio said.

If a person contacts their insurance and finds their options are unreasonable, he encourages them to contact OHA for assistance.

Prizio spent the remainder of the program answering attendees’ various healthcare questions.

The next OHA Lunch & Learn will be on Tuesday, March 22, and will cover the topic of opioids.

OHA’s newsletter previewed the event by sharing, “Opioids — They are addictive and abused far too often. The Connecticut Department of Public Health reported 1,378 deaths in 2020, a 14.6 percent increase in opioid overdose deaths. Our nurse practitioners will explore this subject and provide an overview of the drug overdose epidemic and discussion about Connecticut’s response and prevention strategies.”

Find more information about Office of the Healthcare Advocate by visiting ct.gov/oha, e-mail healthcare.advocate@ct.gov, or call 866-466-4446.

Reporter Alissa Silber can be reached at alissa@thebee.com.