Surprise Billing Law Update

Premier Pulse     September 2021

Belcastro_336x336By Marc Belcastro, DO, system chief medical officer, Premier Health

Beginning January 2022, two new laws will directly change the ability of out-of-network hospital facilities and providers to balance bill patients in certain situations. The two laws are: the federal “End Surprise Billing Act” (effective January 1, 2022) and Ohio House Bill 388 regarding out-of-network care (effective January 12, 2022). Together, these two laws effectively prohibit out-of- network hospital facilities (including the ER), freestanding ERs, physicians providing services at these facilities, ground and air ambulance services, lab services and ancillary services from balance billing patients unless a required notice and consent are obtained from the patient.  Some of the important points to remember are as follows:

  • Effectively these two laws together prohibit any balance billing for ER services, including post ER “stabilization care” as defined in the regulations;
  • For an out-of-network facility or provider to balance bill a patient post-ER and post- ER stabilization care, the facility or provider must provide a required written notice and receive back a signed written consent to provide the care and balance bill the patient;
  • The notice and consent must include an estimate of the balance bill for all services, including an estimate of what the patient’s insurance might pay for the service;
  • The notice and consent must be obtained at least 72 hours prior to the scheduled procedure or service, or, if scheduled in less than 72 hours, at least three (3) hours prior to the scheduled procedure or service;
  • A positive aspect of both laws is that health plan insurers must pay out-of-network facilities and/or providers for care provided to their beneficiaries; the amount of the payment is primarily set by the new Ohio law, and the law also provides a process to arbitrate disputes regarding payment that is overseen by the Ohio Department of Insurance;
  • Neither law applies to physicians in their private practice offices; and
  • There is current lobbying at the federal and state level to either revise or delay proposed regulations.

It is important for providers and their business managers to work with their business and legal advisors to further learn the requirements of these two new laws and to prepare for this change. Some sources for additional information are:

Back to the September 2021 issue of Premier Pulse

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