Balance Billing In Utah: Unraveling The Legalities For The Double-Insured

Balance billing, also known as surprise billing, is a legal practice in Utah. It occurs when a patient receives a balance bill after they receive care from an out-of-network provider or at an out-of-network facility, resulting in unexpected charges. While balance billing is legal in Utah, the state has implemented protections for patients with double insurance coverage to prevent excessive out-of-pocket expenses. The No Surprises Act, which came into effect on January 1, 2022, offers new billing protections for consumers seeking emergency care or non-emergency care from out-of-network providers at in-network facilities. This legislation ensures that patients are only responsible for their in-network cost-sharing amounts, such as copayments, coinsurance, or deductibles, even if they receive care from an out-of-network provider or facility. Additionally, emergency services must continue to be covered without prior authorization, regardless of the provider's network status. These protections aim to shield patients from unexpected financial burdens and provide clarity regarding their rights and responsibilities when seeking medical care.

Balance billing, or surprise billing, is legal in Utah

Surprise billing occurs because some medical providers or facilities may not be contracted with a patient's health insurer, even though they provide services at a hospital or facility that is in the patient's health plan network. As a result, patients may be billed for the difference between what their insurer has agreed to pay the provider and the amount the provider billed for their services.

In Utah, this practice of balance billing is legal. However, as of 2017, 21 states had some form of patient protection laws in place, and Utah was not one of them. However, this may change as the state representative, Jim Dunnigan, has proposed legislation to add protections for consumers from balance billing.

While balance billing is legal in Utah, there are still some protections in place for patients. For example, if a patient has an emergency medical condition and receives emergency services from an out-of-network provider or facility, they are protected from balance billing and can only be billed the in-network cost-sharing amount. Additionally, if a patient receives services from an in-network hospital or ambulatory surgical center, and certain providers there are out-of-network, those providers can only bill the patient the in-network cost-sharing amount and cannot balance bill them.

It is important to note that patients are never required to give up their protections from balance billing and can choose a provider or facility within their health plan's network.

Utah is one of over two dozen states without patient protections

Balance billing, also known as surprise billing, is a legal practice in the United States. It occurs when a patient receives a balance bill after they receive care from an out-of-network provider or at an out-of-network facility, such as a hospital. This can happen for both emergency and non-emergency care, and often the patient is unaware that the provider or facility is out-of-network until they receive the bill.

For example, in 2018, a man named Mike Lyons was treated at an out-of-network emergency room after a rock climbing accident. He received a hospital bill for $51,000, of which his insurance company paid $9,000. The hospital argued that their care had cost more than what the insurance company had paid and billed Lyons for the remaining $42,000. This practice of balance billing left Lyons, and many other Utahns, stuck with large medical bills.

However, as of 2021, Utah has passed legislation to protect consumers from balance billing. The new law, known as the No Surprises Act, prohibits out-of-network providers from billing patients more than their in-network coinsurance, copays, or deductibles for emergency services, even if the facility or provider is out-of-network. The law also protects patients from balance billing for non-emergency services performed by an out-of-network provider at an in-network facility.

While this legislation is a step in the right direction, it is important to note that balance billing is still a legal practice in many states, and patients can still find themselves facing unexpected and costly medical bills. It is crucial for patients to be aware of their rights and protections when it comes to medical billing and to understand the potential costs associated with out-of-network care.

Patients can dispute surprise bills with their insurance company or through an external review

Surprise billing, or balance billing, occurs when a patient receives a bill after receiving care from an out-of-network provider or facility. This can happen for both emergency and non-emergency care. In the past, patients in Utah had little protection from surprise billing, but the No Surprises Act, which came into effect on January 1, 2022, offers patients new billing protections.

If you've received a surprise bill that you believe isn't allowed under the new law, there are several options for disputing it. Firstly, you can file an appeal with your insurance company. Your plan documents will contain information on the review process and how to request a review of your plan's decision.

Secondly, you can request an external review of the company's decision. The No Surprises Act outlines a process for your insurance company and the provider to settle disputes over the provider's charges, ensuring a fair resolution. You can also file a complaint with the Utah Insurance Department. There is also an independent dispute resolution (IDR) process available to settle bills, although this does not include the consumer. Instead, the insurer or provider can choose to start an open negotiation period of 30 business days, after which, if no agreement is reached, either party may use a certified independent resolution entity to decide the payment amount.

Additionally, if you believe you've been wrongly billed, you can contact the relevant authorities, such as the Utah Insurance Department or the U.S. Centers for Medicare & Medicaid Services (CMS). You may also contact your health plan directly, as emergency claims should not be balance billed.

It's important to note that surprise billing protections apply to specific situations and may vary depending on your state and insurance plan.

There is also an independent dispute resolution (IDR) process to settle bills

In Utah, there is an independent dispute resolution (IDR) process to settle bills. This process is managed by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. It is used to determine the payment rates for certain out-of-network charges.

The IDR process can be initiated after a 30-business-day open negotiation period between the health plan, provider, or facility. During this period, the involved parties must attempt to reach an agreement on a payment amount. If they are unable to do so, either party can initiate the IDR process.

In the Federal IDR process, disputing parties choose a third-party entity, known as a certified IDR entity, from a list of certified organizations to resolve their dispute. The provider or facility and the health plan or issuer must submit payment offers and additional information supporting their payment offers to the certified IDR entity. The certified IDR entity then selects one of the two payment offers within 30 business days, and the decision is binding. The losing party in the dispute is responsible for the IDR fees, which can range from $350 to $700 for single determinations and from $475 to $938 for batched determinations.

The IDR process incentivizes good-faith plan and provider offers. It encourages both parties to make reasonable offers, as one of the two offers will be selected by the certified IDR entity. Unless the providers and plans can justify their offer payment amount, very high or very low offers are unlikely to be selected.

The No Surprises Act is a federal law that offers protections related to healthcare services

The Act came into effect on January 1, 2022, and is intended to address unexpected gaps in insurance coverage that result in "surprise medical bills" when patients unknowingly obtain medical services from physicians and providers outside their health insurance network.

Under the No Surprises Act, surprise bills are banned for most emergency services, even if received out-of-network and without prior authorization. It also bans out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. Patients cannot be charged more than in-network cost-sharing for these services.

The Act also bans out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient's visit to an in-network facility. It requires healthcare providers and facilities to give patients an easy-to-understand notice explaining the applicable billing protections and outlining a process for insurance companies and providers to settle disputes over charges.

The No Surprises Act also establishes an independent dispute resolution process for payment disputes between plans and providers. It provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

In addition, the Act requires some healthcare facilities and providers to disclose federal and state patient protections against balance billing and sets forth complaint processes for violations of these protections.

The No Surprises Act is enforced by various federal agencies, including the U.S. Department of Labor, the Department of Health and Human Services, and the Treasury. States also have a role in enforcement, particularly for state-regulated plans.

The Act provides important new federal protections against surprise medical bills, which are a leading cause of affordability concerns for consumers. It aims to reduce out-of-pocket costs for individual patients and prevent unexpected medical bills.

Frequently asked questions