The Department of Health and Human Services has mandated that self-pay patients and patients with non-participating (out-of-network) insurance plans must be given a notice of non-participating status, consent for treatment, and good-faith estimate of costs by the healthcare facility or provider. These documents must be provided 72 hours in advance of scheduled services. When services are scheduled less than 72 hours in advance, these documents must be provided at least 3 hours prior to the scheduled services.
Emergency services are exempt from the good-faith estimate requirement, since such services are not scheduled in advance.
Notice, consent, and good-faith estimates must be obtained from the participant, beneficiary, or enrollee. An authorized representative, as defined by state law, may receive notice, consent, and estimate on behalf of the participant, beneficiary, or enrollee. Once obtained, these documents must be retained by the facility or provider for a period of at least 7-years from the date of service.
If notice, consent, and estimate are not obtained in accordance with the Surprise Billing Act, the non-participating healthcare facility or provider must not bill, and must not hold liable, the participant, beneficiary, or enrollee.
If a patient feels that a non-participating facility or provider has violated any provision of the Surprise Billing Act, they may file a dispute with the Department of Health and Human Services. This includes if the healthcare facility or provider bills in excess of the good faith estimate.
The dispute resolution process must start within 120 calendar days (about 4 months) of the date on the original bill. If the agency agrees with the patient, the patient will pay the amount on the good faith estimate. If the agency agrees with the healthcare facility or provider, the patient will pay the higher fee shown on the bill. There is a $25 fee to use the dispute process.
To learn more or obtain a form to start the dispute process, call 1-877-696-6775 or visit the DHHS website.