Surprise billing
What it is, how to avoid it and what the new legislation means for you
The cost of health care in the United States continues to grow, straining the budgets of families, businesses and taxpayers alike. Priority Health remains committed to providing our members with access to high quality, affordable health care. For years, we've worked to make the cost of care more transparent. In recent years, industry leaders and politicians have passed federal and state legislation that protects you and your loved ones from surprise billing from out-of-network providers.
What is 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 have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your plan’s network.
Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.”
“Surprise billing” is an unexpected balance bill. This can happen when you can’t 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. This can also happen in non-emergency situations at an in-network facility that uses out-of-network providers (such as anesthesiologists).
Some of the most common specialties that result in these surprise bills include PARE providers.
What are PARE providers?
Pathologists
Pathologists examine your labs to help reach a diagnosis for your health concerns.
Anesthesiologists
Anesthesiologists administer medications so you do not feel pain when undergoing surgery.
Radiologists
Radiologists diagnose and treat your injuries and diseases using medical imaging procedures such as X-rays.
Emergency room physicians
Emergency room physicians assess and attend to you when you enter the hospital’s emergency room.
How to avoid a surprise bill
Use Cost Estimator to verify that your provider and facility are in network
Priority Health believes health care costs should be clear. That's why we provide you with our Cost Estimator tool so you can shop for in-network care and know your costs in advance. Copays and deductibles apply based on your plan benefits.
Continuity of Care
If your primary care provider or specialist is leaving Priority Health’s network of providers, you may able to elect to continue receiving transitional care services from them for a period of time. The federal No Surprises Act allows patients to continue to see recently non-par providers for a certain period of time if they meet the criteria for continuation of care services. If you meet the criteria outlined below and would like to continue to see your provider, please contact our Customer Service team at the number on the back of your member ID card or log in to your member account to send us a message.
If you meet any of the criteria outlined below, you may be able to continue to see your provider. If you are:
- Undergoing a course of treatment for a serious and complex condition from the provider or facility;
- Serious and acute illness is defined as:
- In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or
- In the case of a chronic illness or condition, a condition that is—
- Life-threatening, degenerative, potentially disabling, or congenital; and
- Requires specialized medical care over a prolonged period of time.
- Undergoing a course of institutional or inpatient care from the provider or facility;
- Scheduled to undergo non-elective surgery from the provider, including receipt of postoperative care from such provider or facility with respect to such a surgery;
- Pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or
- Are or was determined to be terminally ill and is receiving treatment for such illness from such provider or facility.
What do I need to know about the state and federal legislation?
Out-of-network providers can no longer send you surprise bills without disclosure and your consent for planned services
State protections for members
Governor Whitmer signed into law Michigan's Surprise Billing legislation in October 2020.
In non-emergency situations, out-of-network providers are now required to disclose the estimated cost of care to you at least 14 days in advance of your planned service (or within 14 days if you appointment is sooner). Your signature is required if you agree to pay the amount not covered by your health plan.
Provider's documentation must include:
- A statement that your insurer may not cover all services
- A "good-faith" estimate for services to be provided
- A statement that you may request care from an in-network provider and can contact your health plan to discuss
Note: In emergency situations, or if an out-of-network provider fails to give you the required disclosure before your planned service, you cannot be balance billed.
Federal protections for members
The federal government also passed similar surprise billing legislation in December 2020. This went into effect on Jan. 1, 2022.
Because the state of Michigan has its own surprise billing protections that supersede the federal law, the federal Surprise Billing law is only applicable to air ambulance services, members in a self-funded group health plan, and members residing outside of the state of Michigan.
In all situations where you are presented with paperwork by providers, we encourage you to carefully read before you sign.
When balancing billing isn't 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 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 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.
Answers to common surprise billing questions
I have a procedure planned at an in-network facility in the future. How do I verify that I won’t be balance billed after the fact?
If your good faith estimate from the scheduling provider includes services from an out-of-network provider (such as a pathologist, anesthesiologist, radiologist or emergency room physician) and you wish to request a switch to an in-network provider please contact your scheduling provider. Ask them to help you find an in-network provider for all services you require.
I received emergency care from an in-network facility and got a bill I wasn’t expecting after the procedure. What do I do?
In emergency situations, you cannot be balance billed by out-of-network providers.
I received scheduled care from an in-network facility but got a bill I wasn’t expecting after the procedure. What do I do?
- Under the new legislation, if you or your representative are given—and sign—paperwork provided by an out-of-network provider that includes a disclosure form and a cost estimate at least 14 days in advance of your planned service (or within 14 days if your planned service is sooner), you agree to be balance billed by the out-of-network provider. You bear liability in this instance.
- In an non-emergency situation where an out-of-network provider fails to give you the required disclosure before or within 14 days of your planned service, you cannot be balance billed. Only your applicable in-network coinsurance, copayment, or deductible.
- Check your EOB for applicable copays.
Questions about a surprise bill?
If you believe you’ve been wrongly billed, or you did not receive the required disclosure form, contact us at the number on the back of your Member ID card. Unresolved issues can be directed to the Michigan Department of Insurance and Financial Services Monday through Friday 8 a.m. to 5 p.m. at 877.999.6442 or visit the DIFS website to file a complaint.
Unresolved issues related to air ambulance services, plan members of self-funded groups, or plan members residing outside of Michigan can contact the CMS/Centers for Medicare and Medicaid Services at 800.985.3059 or visit their website.
