What is "balance billing" (sometimes called "surprise billing)?
When a patient sees a doctor or other health care provider, they may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. The patient may have other costs or have to pay the entire bill if they see a provider or visit a health care facility that isn’t in their health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with the patient's health plan. Out-of-network providers may be permitted to bill the patient for the difference between what their 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 the patient's annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when a patient can’t control who is involved in their care—such as when they have an emergency or when they schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
Protections against balance billing
Laws are in place to protect patients from being billed more for out-of-network services than their in-network cost sharing amount (copay, coinsurance, or deductible). For example, in Minnesota, Minn. Stat. 62K.11 protects patients against balance billing in some circumstances. (see https://www.revisor.mn.gov/statutes/cite/62K.11). (See also Minnesota Statutes 62Q.556 – Unauthorized Provider Services.)
Emergency care from an out-of-network provider or facility
The most a patient can be billed for emergency services is their plan’s in-network cost sharing amount. This includes services they may get after they are in stable condition, unless they sign a written consent allowing us to balance bill you for those services.
When balance billing is not allowed, the patient is only responsible for paying their share of the costs (such as copayments, coinsurance, or the deductible that they would pay if the provider or facility was in-network).
The patient's health plan generally must:
• Cover emergency services without requiring the patient to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base the patient's cost sharing for emergency services on what it would pay an in-network provider or facility. This amount must be shown in the patient's Explanation of Benefits.
• Count any amount the patient pays for emergency services on what it would pay an out-of-network services toward the patient's deductible and out-of-pocket limit.
• The patient is not required to get care out-of-network; they can choose a provider or facility in their plan’s network.
Patients are never required to give up their protections from balance billing. They also aren’t required to get care out-of-network. Patients can choose a provider or facility in their plan’s network.
For more information
If a patient believes they have been wrongly billed, they may contact the Centers for Medicare and Medicaid Services (CMS) at 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about patients' rights under federal law.
Visit www.ag.state.mn.us/consumer/health/default.asp for more information about patients' rights under Minnesota law.
Uninsured and self-pay patients
Patients have the right to a written estimate of their medical bill (called a Good Faith Estimate) when:
• Their appointment is scheduled 3 or more days in advance and
• They will not be using insurance to pay for the visit or they do not have insurance.
• They may also request an estimate if one is not automatically provided.
The Good Faith Estimate will include the expected charges of the item or service, such as the cost of a non-emergency clinic visit, plus any tests, procedures, and supplies.
Patients should be sure to save a copy or photo of the Good Faith Estimate. If they receive a bill from us that is at least $400 more than their estimate, they can dispute it. This must be done within 120 calendar days of receiving the bill.
Our patient account representatives can answer questions about Good Faith Estimates and explain the possible costs of a patient's treatment.
Company phone: 612-444-3000
For more information about patients' rights and the No Surprise Bill Act, visit: www.cms.gov/nosurprises