Understanding Surprise Billing Laws by State

Surprise billing laws vary from state to state, so it's essential to understand the specific rules in your area. In California, for example, the state's law requires that out-of-network providers give patients a clear estimate of their costs before providing care.

In some states, like New York, surprise billing is prohibited, and patients are protected from receiving unexpected medical bills. However, in other states, like Texas, patients may still receive surprise bills, but there are limits on how much they can be charged.

To navigate these complex laws, it's crucial to know the specifics of your state's regulations. For instance, in Florida, patients have the right to request a good-faith estimate from their healthcare provider.

Balance billing is a type of surprise bill that can happen when you receive medical care from an out-of-network provider or at an out-of-network facility. This can occur even if you have health insurance, and it's not always clear until you receive the bill.

A surprise bill is an unexpected bill from a health care provider or facility, and balance billing is a specific type of surprise bill that occurs when an out-of-network provider sends a bill directly to the patient for the difference between what the insurer agreed to pay and what the provider billed for their services.

Balance billing isn't allowed for emergency services or some non-emergency services, such as ancillary services like anesthesiology, pathology, radiology, or neonatology. However, it can still happen for other services.

You might be surprised to receive a balance bill, especially if you didn't know the provider or facility was out-of-network. This can happen for both emergency and non-emergency care.

Some types of medical providers and facilities may not be contracted with your health insurer, even if they provide services at a hospital or facility that is in your health plan's provider network. This can lead to balance billing.

Recent state and federal laws have prevented people from getting a surprise medical bill when they receive emergency care from a hospital or certain behavioral health treatment facilities, or if they have a scheduled procedure at an in-network facility and receive care from an out-of-network provider.

In some cases, you may be able to avoid balance billing if you receive emergency care from an out-of-network provider at an in-network facility. However, this is only true if the provider gives you a plain-language explanation of your rights and you give written consent to give up your protections against balance billing.

Related reading: Hipaa Allows a State Preemption. What Does That Mean

As of January 1, 2022, consumers have new billing protections when getting emergency care from out-of-network providers at in-network facilities.

Emergency services must continue to be covered without any prior authorization, regardless of whether or not a provider or facility is in-network.

You can't be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility.

A facility cannot ask you to pay more for care related to emergency medicine, anesthesiology, pathology, radiology, or neonatology — or for services provided by assistant surgeons, hospitalists, and intensivists, or for diagnostic services including radiology and lab services.

Here are some key protections:

To avoid being sent a balance bill, you must give written consent to give up your protections against balance billing when receiving emergency care from an out-of-network provider at an in-network facility.

Insurers have a lot of responsibilities when it comes to surprise billing. They must base their cost-sharing responsibility on what they would pay an in-network provider or facility, and show that amount on your Explanation of Benefits (EOB).

Here's how insurers can help you avoid surprise bills: they must count any amount you pay for emergency services or services provided by an out-of-network provider at an in-network facility toward your deductible and out-of-pocket limit. This can really add up, and help reduce your financial burden.

To help you make informed decisions, insurers must tell you which providers, hospitals, and facilities are in their networks. You can usually find this information on their websites, or by asking them directly.

The Recognized Amount is used to calculate the patient's in-network co-insurance for out-of-network emergency or provider services.

This amount is the median of a plan's contracted rates on January 31, 2019, which is recognized by the plan as the total maximum payment for the service furnished by a provider in the same specialty or geographic region.

The reimbursement amounts for out-of-network providers can be reached through a consent agreement between the parties or through an Independent Dispute Resolution (IDR).

In the case of an IDR, a CMS-approved IDR entity appoints an arbiter to decide on the final amount the payer has to pay to the provider.

The SCDOI has enforcement over issuers, while providers and facilities will be under federal enforcement. This means that insurance companies and HMOs will be held accountable for following the law, while healthcare providers and facilities will be subject to federal regulations.

Consumers have the right to appeal health plan denials and decisions that bill them for an amount higher than allowable under the law. If the plan upholds its decision, an independent external reviewer will make a final determination.

If you believe you've received a surprise medical bill from a provider, you have several options to consider.

Check this out: Is Hipaa State or Federal Law

The enforcement and appeals process is a crucial part of the law, and it's essential to understand how it works.

The South Carolina Department of Insurance (SCDOI) has enforcement over insurance companies and Health Maintenance Organizations (HMOs), while providers and facilities will be under federal enforcement.

If your health plan denies a claim or bills you for more than what's allowed, you have the right to appeal. The plan will review your appeal, and if they uphold their decision, an independent external reviewer will make a final determination.

You'll have several options if you receive a surprise medical bill from a provider for services like emergency care or non-emergency care at an in-network facility.

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The arbitration process between providers and insurers is a crucial aspect of the No Surprises Act. It provides a fair process for resolving out-of-network bills without additional cost to patients.

Under this process, if providers and insurers disagree over a payment, they need to work it out themselves or use a new arbitration process. This means patients no longer have to get involved in negotiations or disputes between their providers and insurer.

Check this out: Florida Balance Billing Law