Surprise billing legislation

Background

On Oct. 22, 2020, two laws (Public Act No. 234 and No. 235) were enacted that prohibit out-of-network providers from sending surprise bills to patients. Surprise billing, or balance billing, has never been allowed for participating providers. Surprise billing happens primarily when a patient receives care at in-network facility but the provider may not be contracted with the insurance carrier and is considered an out-of-network provider.

What providers need to do

Under the law, out-of-network providers are required to give disclosures ahead of providing service to non-emergency patients, and aren’t allowed to balance bill patients in emergency scenarios.

If the provider fails to give the disclosure of if the member does not sign, the provider cannot balance bill the member. If they approve the service and sign, the patient may be balance billed.

Out-of-network providers are required to give the following to non-emergency patients:

    • A statement that their insurer may not cover all services
    • A “good-faith” estimate for services to be provided
    • A statement that they may request care from an in-network provider
    • An acknowledgement of understanding signed by the patient or their representative that the provider has provided the member with a disclosure form and cost estimate at least 14 days in advance of the service. The form, if signed by the member, would allow the member to be balance billed.

Payment for out-of-network providers

Out-of-network PARE providers (pathologists, anesthesiologists, radiologists and emergency room physicians) who submit claims to Priority Health will be paid 150% of what Medicare pays OR the plan median contracted rate (for their PARE specialty) for the medical service, whichever is greater. The median amounts are based on the provider’s location and specialty and our in-network rates. They are refreshed annually.

Surprise billing payment disputes

If an out-of-network provider disagrees with how they’ve been reimbursed related to surprise billing, they have the right to initiate a 30-day open negotiation period.

To initiate an open negotiation period, contact Multiplan at provider.multiplan.com, NSAService@multiplan.com or 888.593.7427. Be prepared to share your name, phone number and message, including the required open negotiation letter with a description of the item(s) or service(s), claim #, provider name and NPI along with dates of service.

Please also notify us at NSA@priorityhealth.com.