Effective January 2022, the Federal Government enacted the “No Surprises Act” (NSA). The NSA is designed to protect consumers from receiving surprise medical bills. For example, in the past, if you had surgery and the surgeon and nurses were covered by your insurance, but the anesthesiologist was out of network, or they had to bring in a specialist who was out of network, you would have been responsible for those total bills. Under the NSA, you now have the right to a Good Faith Estimate of how much a given procedure will cost. Although some of the following may appear less applicable to therapy sessions, it is your legal right to have this information. Please read on for the official notices:
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE
MEDICAL BILLS
(OMB Control Number: 0938-1401)
When you get emergency care or get 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.
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 have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out of network” describes providers and facilities that haven’t signed a contract with your health plan. 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.” This amount is likely more than in-network costs 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 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.
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 can’t be balance billed for these emergency services. This includes services you may get after you’re 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, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out of network providers can’t balance bill you unless you give written consent and give up your protections.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out of network. You can choose a provider or facility in your plan’s network.
When balance 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.
If you believe you’ve been wrongly billed for therapy services, you may contact the following, depending on your location: Virginia Department of Health Professions at 1-800-533-1560 or enfcomplaints@dhp.virginia.gov or District of Columbia DC Health at 202-442-5955 or doh@dc.gov – if you are in a PSYPACT state, please contact me at 703-795-7929 or drjeanne@drjeannemiller.com and I will assist you in identifying whom you should contact in your state.
STANDARD NOTICE
“Right to Receive a Good Faith Estimate of Expected Charges”
Under the No Surprises Act
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care providers give you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
You have the right to dispute any bill more than $400 over your Good Faith Estimate. You may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
Make sure to save or take a photo of any Good Faith Estimates you receive from providers in a safe place. You may need them if you are billed a higher amount than estimated.
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Although psychologists and other mental health providers have always provided our fees and our in-network or out-of-network status up front, so that consumers know in advance how much they will pay for each therapy session, under the requirements of the NSA, I will also provide Good Faith Estimates to qualifying new and existing patients. If you have any questions about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call or email me.