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Surprise Billing FAQs

Surprise Billing FAQs

Consumers

The surprise billing law protects patients from receiving and paying surprise medical bills above the patient's in-network rate from health care providers for emergency care or, in certain circumstances, unanticipated out-of-network care. Cost sharing amounts, which include coinsurance, copayments, and deductibles, are limited to the patient’s in-network amounts.

Before the law, patients were responsible for paying surprise medical bills, oftentimes ranging hundreds to thousands of dollars above the in-network rate, arising from unanticipated out-of-network situations. Price and payment reconciliation is now solely between the patient's health care provider and health insurer.

What is surprise billing and how does it occur?

Surprise billing happens when a patient receives an unexpected bill after unanticipated care from an out-of-network health care provider, which can occur at an in-network health care facility such as a hospital, or at an out-of-network health care facility. It can happen for both emergency and non-emergency care. Typically, patients are unaware that the health care provider or health care facility is out-of-network until they receive the bill.

Treatment Situations and Surprise Billing:

Emergency Situation

  • An individual with insurance has an unanticipated, medical emergency event requiring "emergency services". This individual is taken to an “out-of-network” health care facility and receives emergency care. Due to the emergency situation, the individual was unable to select an in-network health care provider. 
  • Similarly, the individual is taken to an in-network health care facility but received emergency care from out-of-network health care providers working with that health care facility. Because of the emergency, the individual was unable to select an in-network health care facility or health care provider.

Non-Emergency Situation

  • An individual with insurance schedules an elective treatment or nonemergency care appointment with an in-network health care provider. During the scheduled visit to the health care provider's facility, the patient receives services from an out-of-network health care provider. This could be a service from a doctor or related to imaging, laboratory services, etc. The patient, after this "unanticipated out-of-network care" then receives a surprise bill for out-of-network services received even though the treatment occurred in an in-network health care facility. 

Described above, "emergency services" in both in-network and out-of-network settings and "unanticipated out-of-network care" mean the following, according to the law:

Emergency Services

  • Medical screening examinations to determine whether an emergency medical condition exists.
  • Treatment that is necessary to stabilize an emergency medical condition.
  • Appropriate transfers prior to an emergency medical condition stabilization.

Unanticipated Out-of-Network Care 

Health care services covered under a health benefit plan and provided by an out-of-network health care provider when either of the following conditions applies:

  • The covered person did not have the ability to request such services from an in-network health care provider.
  • The services provided were emergency services.

For additional treatment situation examples, including about consent, click here.

Are "balance billing" and "surprise billing" the same?

The term “balance billing” and "surprise billing" are sometimes interchangeably used. 

Specifically, balance billing happens when a patient's health insurer only pays for a portion of the medical bill (usually the negotiated amount for services equal to the health plan’s in-network rate). The patient is then responsible for paying the balance between their in-network rate and the out-of-network rate. Balance billing is permitted if a patient chooses medical services from an out-of-network health care facility and provider.

Surprise billing is a form of balance billing. It happens when a patient receives an unexpected bill after unanticipated care from an out-of-network health care provider, which can occur at an in-network health care facility such as a hospital, or at an out-of-network health care facility. It can happen for both emergency and non-emergency care. Typically, patients are unaware that the health care provider or health care facility is out-of-network until they receive the bill.

The surprise billing law protects patients from having to pay surprise medical bills from health care providers for emergency care or, in certain circumstances, unexpected out-of-network care of an amount above the patient's in-network rate, and for additional cost-sharing such as copayments, coinsurance, and deductibles.

Is a patient obligated to pay a surprise medical bill?

The surprise billing law protects patients from receiving and paying surprise medical bills above the patient's in-network rate from health care providers for emergency care or, in certain circumstances, unanticipated out-of-network care. Cost sharing amounts, which include coinsurance, copayments, and deductibles, are limited to the patient’s in-network amounts.

For patients billed for receiving out-of-network treatment due to an unanticipated situation, they are held harmless. Health care providers are prohibited from balance billing any of these costs.

Before the law, patients were responsible for paying surprise medical bills, oftentimes ranging hundreds to thousands of dollars above the in-network rate. Price and payment reconciliation is now solely between the patient's health care provider and health insurer.

Are consumers protected from air and ground ambulance surprise billing situations?

The Ohio and federal law work together to protect consumers from air and ground ambulances surprise billing. Federal law applies to air ambulance and Ohio law to ground ambulance surprise billing situations

What should I do if I receive a surprise medical bill?

Patients should not receive surprise bills for unanticipated out-of-network care for services performed on or after January 1, 2022.

If you receive a surprise bill that you believe is prohibited by state or federal law, first, try to resolve the dispute yourself with your health insurer and health care provider. If the dispute remains unresolved, contact the Ohio Department of Insurance through www.insurance.ohio.gov, consumer.complaint@insurance.ohio.gov, or 800-686-1526 to file a complaint.

If I am not responsible for paying my surprise bill, who is?

The handling of price and payment reconciliation is solely between the patient’s health care provider and health insurer. A health insurer's payment to the health care provider shall be the greatest of the following three amounts:

  • The median in-network rate for the services for that geographic region in which the services were performed.  
  • The out-of-network rate, also known as the usual, customary, and reasonable rate.
  • The Medicare rate.

A health care provider can initiate negotiations, and if necessary go to arbitration, with the health insurer in lieu of accepting the health insurer's reimbursement amount.

Are health care facilities and health care providers required to explain my rights regarding my protections against surprise billing? 

Under the federal law, health care facilities and health care providers are required to make publicly available, post on a public website of the provider or facility (if applicable), and provide a one-page notice that includes information in clear and understandable language on: 

  • Restrictions on providers and facilities regarding balance billing in certain circumstances.
  • Applicable state law protections against balance billing.
  • Information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

In addition, the federal government developed standard notice and consent documents for use by health care facilities and health care providers to give to patients relating to the differences between in-network and out-of-network care.

Will I receive a new health insurance identification card because of the surprise billing law?

Health insurers are required to make modifications to their identification cards to denote the consumer’s health insurer is subject to Ohio’s regulations on surprise billing. Identification cards provided to a covered person, if any, must have the letters "ODI" prominently displayed on the front of the card or document.  

In addition, if a health insurer permits health care providers to access a covered person's eligibility or coverage information through an electronic system, the system must prominently display a statement that the covered person's health insurer is subject to Ohio Revised Code 3902.50 to 3902.54, which is Ohio's surprise billing law.

Are there stipulations in the law for health insurers to keep their health care provider network information updated?

Provisions in the law require insurance companies to keep their provider directories updated. They also must limit your copays, coinsurance, or deductibles to in-network amounts if you rely on inaccurate information in a provider directory. For more on health care provider network transparency in Ohio, click here.

Health Care Providers and Health Insurers

The surprise billing law prohibits balance billing a patient for their unanticipated out-of-network care above the patient's in-network rate for emergency care or, in certain circumstances, unanticipated out-of-network care. Cost sharing amounts, which include coinsurance, copayments, and deductibles, are limited to the patient’s in-network amounts.

This represents a systemic shift from patients to health care providers and health insurers in many areas, including payment reconciliation.

Health care providers and health insurers are impacted when patients receive health care services under two conditions: Receive emergency care at an out-of-network health care provider or at an out-of-network health care facility. Receive unanticipated out-of-network care at an in-network health care facility, but services are rendered by an out-of-network health care provider.

Are health care facilities and health care providers required to explain to a patient their rights regarding protections against surprise billing? 

Under the federal law, health care facilities and health care providers are required to make publicly available, post on a public website of the provider or facility (if applicable), and provide a one-page notice that includes information in clear and understandable language on: 

  • Restrictions on providers and facilities regarding balance billing in certain circumstances.
  • Applicable state law protections against balance billing.
  • Information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

In addition, the federal government developed standard notice and consent documents for use by health care facilities and health care providers to give to patients relating to the differences between in-network and out-of-network care.

Since the patient is not responsible for payment in surprise billing situations, what is the payment reconciliation process that health care providers and health insurers must follow?

The desired outcome of the surprise billing law is for health insurers and health care providers to achieve a reimbursement amount for unanticipated out-of-network care reflective of market costs and conditions.

The law established a process for health insurers and health care providers to negotiate claim amounts that reflect market conditions to compensate health care providers. That reimbursement shall be the greatest of the following three amounts:

  • The median in-network rate for the services for that geographic region in which the service is performed.  
  • The out-of-network rate, also known as the usual, customary, and reasonable rate.
  • The Medicare rate.

For purposes of determining the amount negotiated with in-network health care providers, facilities, emergency facilities, or ambulances for the service in question in a geographic region under a health benefit plan, a health insurer shall use the geographic region in which the service was performed. 

Ohio has 14 metropolitan statistical areas. All counties not in a metropolitan statistical area will be compared to other nonmetropolitan statistical areas in the state as shown in this official Ohio Metropolitan Statistical Areas map.

Click here further understand how the geographic regions are organized.

Are there prompt pay requirements for health insurers when reimbursing health care providers?  

Prompt payment requirements of health insurers remain in force except with respect to a claim during a period of negotiation. A health plan issuer shall send an initial claim payment   as its intended reimbursement required by Ohio Revised Code 3902.51 (B)(1) to the health care provider, facility, emergency facility, or ambulance in compliance with Ohio’s prompt pay laws (sections 3901.38 to 3901.3814 of the Ohio Revised Code).

What is the role of health care providers to ensure prompt payment from a health insurer?

In a request for reimbursement of a health care service, the health care provider, facility, emergency facility, or ambulance shall include the proper billing code for the service for which reimbursement is requested. Such request for reimbursement shall also include: 

  • Sufficient information for the health insurer to identify the facility where a health care service was provided.
  • Sufficient information for the health insurer to identify a request for reimbursement where the health care provider, facility, emergency facility, or ambulance has met the good faith estimate and affirmative consent conditions contained in  Ohio Revised Code 3902.51 (E)(1).

What negotiation channels are available to a health care provider in disagreement with a health insurer's reimbursement amount?

A health care provider is permitted to initiate negotiations with the health insurer in lieu of accepting the reimbursement amount.

If this occurs, the parties have 30 days to negotiate an out-of-network reimbursement rate and have the right to seek arbitration if at an impasse. Cases eligible for arbitration can be no more than one-year old and the billed amount must exceed $750. Claims may be bundled according to exact billing codes to get to the $750 threshold. 

The law requires the Ohio Department of Insurance to select an entity to perform arbitrations. Losing parties pay seventy percent and winners pay thirty percent of all arbitration fees. 

What is the procedure for a health care provider to notify a health insurer of a desire to negotiate reimbursement?

The health care provider, facility, emergency facility, or ambulance shall, within 30 business days of receiving reimbursement for unanticipated out-of-network care, notify the health insurer that the health care provider, facility, emergency facility, or ambulance chooses to negotiate reimbursement. 

Failure to notify the health insurer of an intent to negotiate within the timeframe set forth shall be considered acceptance of the health insurer's reimbursement.

If the health care provider, facility, emergency facility, or ambulance timely notifies the health insurer of its intent to negotiate, the health insurer shall, upon request, disclose to the health care provider, facility, emergency facility, or ambulance each reimbursement amount the health insurer calculated for the claim pursuant to Ohio Revised Code 3902.51 (B)(1).

If during a period of negotiation, the health insurer and the health care provider, facility, emergency facility, or ambulance agree on a new reimbursement rate for a claim, then the health insurer shall send payment directly to the health care provider, facility, emergency facility, or ambulance within 30 calendar days. If during a period of negotiation, the health insurer and the health care provider, facility, emergency facility, or ambulance agree on a reimbursement rate for a claim, then that claim is not eligible for arbitration.

If negotiation has not successfully concluded within 30 business days, or if both parties agree that they are at an impasse, a health care provider, facility, emergency facility, or ambulance may choose to arbitrate that claim so long as the claim meets the eligibility requirements of the law in Ohio Revised Code 3902.52 (A)(1).

How does the arbitration process work?  

If dissatisfied with a health insurer's reimbursement amount, a health care provider is permitted to initiate a negotiation process, which can include requesting arbitration. Initiating arbitration is done through a portal on the Ohio Department of Insurance website.  The state’s designated arbitration entity for reimbursement disputes for surprise billing is Maximus Federal Services.

Claims must exceed $750 and occur within a year of the request. The bundling of arbitration claims, up to 15 claims, is allowed as long as certain requirements in the law, pursuant to Ohio Revised Code 3902.52 (A) (1) are met. For purposes of bundling claims for arbitration, the term health care provider includes a practice of health care providers to the extent such health care providers contract with health insurers as a single practice.

Arbitrators are required to perform arbitration on a flat-fee basis with no additional costs for bundled claims with the non-prevailing party paying seventy percent of the costs and the remainder of thirty percent paid by the prevailing party.

Arbitration Steps

  • A health care provider, facility, emergency facility, or ambulance may request arbitration to determine the reimbursement for a claim or claims that are eligible for arbitration, pursuant to Ohio Revised Code section 3902.52.
  • Requests for arbitration shall be submitted to the Ohio Department of Insurance electronically on a form or through a system prescribed by the department's superintendent.
  • Upon receipt of a complete request for arbitration, the superintendent shall notify the contracted arbitration entity of the request for arbitration within four business days.
  • The contracted arbitration entity shall assign an arbitrator within 10 business days and shall provide notice to the health insurer and health care provider, facility, emergency facility, or ambulance.
  • Each party shall submit its final offer and supporting evidence, if any, to the arbitrator within 10 business days after an arbitrator is assigned. The final offer submitted to the arbitrator by either party shall be an amount the submitting party considers a fair reimbursement rate.
  • The arbitrator shall consider the evidence submitted by the parties and render a decision within 30 business days.
  • If the arbitrator determines that the final offer submitted by the health care provider, facility, emergency facility, or ambulance best reflects a fair reimbursement rate, the health insurer shall pay the difference, if any, between the reimbursement rate selected by the arbitrator and the initial payment made by the health insurer pursuant to Ohio Revised Code 3902.51 (B)(1)
  • The health insurer shall pay the reimbursement directly to the health care provider, facility, emergency facility, or ambulance within thirty calendar days of the arbitrator's decision.
  • If the arbitrator determines that the final offer submitted by the health insurer best reflects a fair reimbursement rate, the health care provider, facility, emergency facility, or ambulance shall pay the health plan issuer the difference, if any, between the health insurer's reimbursement rate selected by the arbitrator and the initial payment made by the health insurer pursuant to Ohio Revised Code 3902.51 (B)(1)
  • The health care provider, facility, emergency facility, or ambulance, shall pay the reimbursement directly to the health insurer within 30 calendar days of the arbitrator's decision.

Costs Involved

  • The arbitration entity shall perform each arbitration on a flat-fee basis.
  • There shall be no additional costs for a single arbitration of up to 15 bundled claims.
  • The non-prevailing party shall pay seventy percent of the arbitrator's fees, and the prevailing party shall pay thirty percent.
    • For purposes of this rule, the non-prevailing party shall be the party whose final offer was not selected by the arbitrator. If multiple claims are bundled for a single arbitration, the non-prevailing party shall be the party whose final offer for each claim was selected fewer times by the arbitrator.
    • For purposes of this rule, the prevailing party shall be the party whose final offer was selected by the arbitrator. If multiple claims are bundled for a single arbitration, the prevailing party shall be the party whose final offer for each claim was selected more times by the arbitrator.
  • In the event that multiple claims are bundled in a single arbitration and the arbitrator selects a final offer from each party the same number of times, then there is no prevailing party and each party shall pay fifty percent of the arbitrator's fees.
  • Each party shall bear its own costs for all other expenses related to arbitration.

What is permissible evidence for the involved parties during arbitration?

Submission of Evidence for Purposes of Arbitration

  • Each party may submit evidence relating to the factors contained in Ohio Revised Code 3902.52 (C) except:
    • No party may submit billed charges as evidence.
    • No party may submit public payer rates such as Medicare or Medicaid reimbursement amounts as evidence.
  • Evidence must be in a form that can be verified and authenticated.
  • Evidence must be in a format compatible with the secure portal utilized by the arbitration entity. *Medicare Medicaid

Are health insurers required to issue new insurance identification cards to their customers?

Health insurers are required to make modifications to their identification cards to denote the consumer’s health plan is subject to Ohio’s regulations on surprise billing. This requirement will aid both the health insurer and health care providers with compliance and obtaining reimbursement for unanticipated out-of-network care. 

Identification Cards Requirements

  • Identification cards provided to a covered person, if any, must clearly and conspicuously denote the letters "ODI" prominently displayed on the front of the card or document. 
  • If a health insurer permits providers to access a covered person's eligibility or coverage information through an electronic system, the system must prominently display a statement that the covered person's health insurer is subject to 3902.50 through 3902.54 of the Ohio Revised Code.

Are there stipulations in the law for health insurers to keep their health care provider network information updated?

Provisions in the law require insurance companies to keep their provider directories updated. They also must limit their copays, coinsurance, or deductibles to in-network amounts if patients has to rely on inaccurate information in a provider directory. For more on health care provider network transparency in Ohio, click here.

Any health care provider or health care facility that has or has had a contractual relationship with a health benefit plan or health insurance issuer to provide items or services under such plan or insurance coverage must:

  • Submit provider directory information to a plan or issuer, at a minimum:
    • At the beginning of the network agreement with a plan or issuer
    • At the time of termination of a network agreement with a plan or issuer
    • When there are material changes to the content of the provider directory information of the provider or facility
    • Upon request by the plan or issuer
    • At any other time determined appropriate by the provider, facility or the U.S. Department of Health and Human Services (HHS).
  • Reimburse beneficiaries, enrollees or participants who relied on an incorrect provider directory and paid a provider bill in excess of the in-network cost-sharing amount (i.e., the difference between the patient’s in-network cost-sharing and the amount that the patient paid the provider previously).