Surprise Billing

Balance Billing

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a hospital or ambulatory surgery center (health care facility) that is not in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health insurance plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and your cost-sharing responsibilities and the full amount charged for a service. This amount is called "balance billing" and is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care. For example, when you have an emergency, or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider, you may incur out-of-network costs.

Situations Protected from Balance Billing

Emergency Services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may collect from you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for the difference for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain Services at an In-Network Hospital or Ambulatory Surgical Center

When you receive non-emergency services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to hospital-based providers: emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers (such as surgeons and other non-hospital-based providers) can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

What Is the Patient’s Responsibility if Balance Billing Is Not Allowed?

You are only responsible for paying your cost-share responsibility (copayments, coinsurance and deductibles) that you would pay if the provider or facility was in-network. Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

• cover emergency services without requiring you to get approval (prior authorization) for services in advance.
• cover emergency services by out-of-network providers.
• base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or in-network facility and show that amount in your explanation of benefits.
• count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Your Right to a “Good Faith Estimate” for Non-Emergency Services

Under the law, health care providers must give patients who do not have insurance, or who are not using insurance, a cost estimate (“Good Faith Estimate”) of the bill for non-emergency medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, drugs, equipment and hospital fees.

Your health care provider must give you a Good Faith Estimate in writing for scheduled services within three days of a request, within three days of scheduling the procedures, or one day before the procedure if scheduled less than three days in advance. You can ask your health care provider for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

What to Do if You Have Been Wrongly Billed

If you believe you’ve been wrongly billed, you may contact Jim Stanzell, Corporate Compliance Officer for North Mississippi Health Services, at JStanzell@nmhs.net.

Visit the Centers for Medicare and Medicaid Services for more information about your rights under federal law.