This is the 3rd installment of the No Surprise Act series where we will take a look at how the rule applies to the emergency setting. In my last post, I outlined the highlights of what the NSA impacts for out-of-network providers in an in-network facility:
- How does the in-network cost-sharing and insurance payment work?
- What steps would need to be taken to balance bill?
In an emergency setting, balance billing is prohibited. This includes post-stabilization in observation, inpatient, and outpatient places of service.
If a patient was seen in an emergency setting but it was determined that the patient does not have a condition which required emergency services, then there is an option for providers to obtain a consent form and balance bill the patient for the post-stabilization services. The following criteria must be met:
- The patient is stable enough to travel to an in-network provider/facility.
- The patient is provided written notice and is able to consent to out-of-network post-stabilization care.
- The provider/facility complies with any and all state laws.
If a practice does have the patient sign a consent form and the services are eligible for balance billing, providers may need to indicate on the insurance claims that services were performed at an in-network facility and provide a copy of the signed consent with the claim submission. For patient invoices, providers may need to also send copies of the consent form with the bill to the patient.
Providers can also bill the patient’s insurance as out-of-network and follow the IDR process if they wish to negotiate a different rate with the health plan.
