Patient Rights & Billing

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network

hospital or ambulatory surgical center, you are protected from balance billing. In these cases,

you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out of pocket costs

like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the

entire bill if you see a provider or a visit a health care facility that isn’t in your health plan’s

network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health

plan to provide services. Out-of-network providers may be allowed to bill you for the difference

between what your plan pays the provider and the full amount charged by the provider. This is

called “balance billing.” This amount is likely more than in-network costs for the same service

and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is

involved in your care-like when you have an emergency or when you schedule a visit at an in-

network facility but are unexpectedly treated by an out-of-network provider. Surprise medical

bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency Services: If you have an emergency medical condition and get emergency services

from an out-of-network provider or facility, the most they can bill you is your plan’s in-network

cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance

billed for these emergency services. This includes services you may get after you’re in a stable

condition, unless you give written consent and give up your protections not to be balance billed

for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center: When you get services

from an in-network hospital or ambulatory surgical center, certain providers there may be out-

of-network. In these cases, the most those providers can bill you is your plan’s in network cost-

sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology,

laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers

can’t balance bill you and may not ask you to give up your protections not to be balanced billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t

balance bill you, unless you give written consent and give up your protections.

• You’re never required to give up your protections from balance billing. You also aren’t

  required to get out-of-network care. You can choose a provider or facility in your plan’s

  network.

  When balance billing isn’t allowed, you also have these protections:

  • You’re only responsible for paying your share of the cost (like copayments, coinsurance,

  and deductible that you would pay if the provider or facility was in-network). Your health

  plan will pay any additional costs to out-of-network providers and facilities directly.

  • Generally, your health plan must:

  o Cover emergency services without requiring you to get approval for services in

  advance (also known as “prior authorization”).

  o Cover emergency services by out-of-network providers.

  o Base what you owe the provider or facility (cost-sharing) on what it would pay an

  in-network provider or facility and show that amount in your explanation of

  benefits.

  o Count any amount you pay for emergency services or out of network services

  toward your in-network deductible and out-of-pocket limit.

  If you think you’ve been wrongly billed, you may file a complaint with your health insurer with

  a copy of the bill. If you do not agree with your health insurer’s response, you can file a complaint

  with the California Department of Insurance at 800-927-4357 or online at:

  https://www.insurance.ca.gov/01-consumers/101-help/

  The federal phone number for information and complaints is: 1-800-985-3059. Visit

  www.cms.gov/nosurprises/ for more information about your rights under federal law

SCEMG’s billing company is Phycon. If you have any questions regarding your bill, please contact Phycon’s billing representative: Sam Sossa at (800) 477-8909 or sbossa@ipsmed.com.