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. And in 2020, industry leaders and politicians passed new legislation that protects you and your loved ones from surprise billing from out-of-network providers.
What is surprise billing?
Surprise billing, or balance billing, occurs when you or a family member receives care at an in-network facility but from an out-of-network provider.
Some of the most common specialties that result in these surprise bills include PARE providers.
What are PARE providers?
What do I need to know about the new legislation?
Out-of-network providers can no longer send you surprise bills without disclosure for planned services
New legislation was passed to protect members from surprise billing. Two bills were signed into Michigan law by Governor Whitmer in October 2020 that forbid providers from sending surprise bills to members. The federal government also passed similar bills in December 2020.
In non-emergency situations, out-of-network providers are now required to disclose the estimated costs of care to you at least 14 days in advance of your planned service. 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
- An acknowledgment of understanding that the PARE provider has provided you with a disclosure form and cost estimate at least 14 days in advance of your planned service. If you sign this form, you are agreeing to be balance billed.
Note: In emergency situations, or if an out-of-network PARE provider fails to give you the required disclosures, you bear no liability and cannot be balance billed.
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 billed by out-of-network PARE 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 a PARE provider that includes a disclosure form and a cost estimate at least 14 days in advance of a service that you receive, you agree to be balance billed by the PARE provider. You bear liability in this instance.
- In a non-emergency situation where an out-of-network PARE provider fails to give you the required disclosure 14 days in advance of the procedure, you don't bear liability and cannot be balance billed.
- Check your EOB for applicable copays.
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.