Your Rights and Protections Against Surprise Medical Bills

My clinic is not a crisis center, however there may be a rare occasion when behavioral crisis care is provided. Please note, if you are in a crisis situation and receive care from Beth G. White, LCSW, PLLC, you must sign a consent for crisis services to be provided. This consent form is available in the clinic and may also be provided via email. This policy provides compliance with the Federal No Surprises Act. Learn more about your rights and protections against surprise medical bills:

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. In these cases, you should not be charged more than your plan’s copayments, coinsurance and/or deductible. 

What is “balance billing?" (sometimes called “surprise 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 be required to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network. 

Out-of-network describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your insurance plan pays an in-network provider and the full amount charged for a service. This amount is likely more than an in-network provider would charge you (due to agreements related to copays, coinsurance, contracted rates) 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 cannot control who is involved in your care - like 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 are protected from balance billing for: 

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 bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may receive after you are 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 get 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 emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed. 

If you receive other services at these in-network facilities, out-of-network providers cannot balance bill you unless you give written consent and give up your protections.

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

When balance billing is not allowed, you also have the following protections:

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

Your health plan generally must: 

Cover emergency services without requiring you to get approval for services in advance (prior authorization). 

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 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. 

If you believe you’ve been wrongly billed, you may contact: (800) 985-3059 or visit https://www.cms.gov/nosurprises/consumers for more information about your rights.