Surprise Out-of-network Bill Dispute Resolution
8/20/2018: See bottom of this page for a Notice of Proposed Rulemaking; Notice of Comment Period; Notice of Hearing.
What is a "surprise bill"?
Balance billing – or a surprise medical bill – happens when you get a bill from a doctor, durable medical equipment provider, or other health care provider who isn’t part of your health plan’s network. Often, consumers didn’t know they were getting care from out-of-network providers. For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the copays, deductibles, and coinsurance as well as any other amounts that the health plan did not pay.
How can I protect myself from surprise bills?
- For planned procedures, find out in advance whether your providers are contracted with your health plan. This is especially important in the case of facility-based providers, such as radiologists, anesthesiologists, pathologists, and emergency room physicians. Even if a hospital is in your health plan's network, some doctors who provide services there might not be.
- Call your health plan to make sure the services you will receive are covered under your policy. If the services are not covered, you will have to pay the charges, and the provider's bill will not be eligible for the arbitration process. If you are told the services are not covered under your policy and you believe that they are, you may wish to file a health care appeal.
- Shop around. Web sites like NewChoicehealth.com and FairHealthConsumer.org can help you estimate the prices of various procedures.
- If there aren’t any contracted providers available, your health plan might be able to work out a discounted payment. You also might be able to ask your doctor or provider in advance if they can make payment options available.
- If your health care provider is not contracted under your policy, the provider is required to provide you a disclosure notice within a reasonable amount of time before you receive health care services. The disclosure notice is required to tell you ALL the following:
- The name of the health care provider;
- The fact that the health care provider is not contracted under your health plan;
- The estimated total cost the provider or the provider's representative will bill for the health care service;
- Notice that you are not required to sign the disclosure notice in order to receive medical care, and if you sign the disclosure notice, you waive any rights to dispute resolution (arbitration).
I got a surprise bill. What can I do about it?
- Call the health care provider that sent the bill and discuss your concerns. In most cases, Arizona law requires providers to provide an itemized bill on request, so review the charges carefully. Some providers might accept a lower payment. You can compare the amount you were charged to the average market price using websites like NewChoicehealth.com, and FairHealthConsumer.org.
- Submit a request for arbitration to the Arizona Department of Insurance if you believe the bill you received is eligible for arbitration. The dispute resolution (arbitration) process does not apply to:
- A bill for a health care service the enrollee received before January 1, 2019;
- A bill for a health care service provided more than a year before the enrollee submits a request for arbitration (extended by any time the bill was the subject of a health care appeal);
- A bill that is less than $1,000 after deducting the enrollee's copay, coinsurance and deductible;
- Limited benefit coverage;
- Health and accident coverage for state employees and their dependents;
- Self-funded or self-insured employee benefit plans preempted by the Employee Retirement Income Security Act of 1974 (a.k.a. ERISA);
- Health plans that exclude out-of-network coverage unless otherwise required by law;
- Health care services that are not covered by the health plan;
- Provider or health facility charges that an individual agreed to directly pay rather than using the health plan;
- Provider or health facility charges for which the enrollee signed a disclosure notice on which the enrollee was provided information required by Arizona law, thereby resulting in the enrollee waiving rights to arbitration if the amount of the provider's bill was no greater than the estimated total cost that the provider included on the disclosure notice;
- A bill that is the subject of a health care appeal that has not been decided;
- A bill that is the subject of a legal action that the enrollee initiated;
- A bill that was previously settled or decided through the dispute resolution (arbitration) process.
How can I use the dispute resolution (arbitration) procedure to resolve a surprise bill?
The following is an overview of the dispute resolution process:
- The enrollee submits a request for dispute resolution to the Arizona Department of Insurance ("Department").
- The Department evaluates the request to determine whether it may qualify for arbitration, and if not, the Department notifies the enrollee of the reason the request did not qualify for arbitration (and the process ends).
- OTHERWISE, the Department sends the enrollee's request for dispute resolution to the insurer and the health care provider and may ask for additional information from the enrollee, insurer and provider to help the Department make a final decision as to whether the surprise bill is eligible for the arbitration process,
- If the enrollee does not respond to a Department request for additional information, the enrollee's request for dispute resolution is deemed to have been withdrawn, and the Department will notify the enrollee of this fact (and the process ends).
- If the Department determines from information provided that the surprise bill does not qualify for the dispute resolution process, the Department will notify the enrollee of the reason (and the process ends).
- OTHERWISE, the Department arranges an informal settlement teleconference (IST) in which the enrollee (or authorized representative), insurer and provider (or authorized representative) must all participate.
- If the enrollee participates in the IST, the insurer will notify the Department of the outcome and the enrollee can only be held responsible for paying the amount of the enrollee's cost-sharing requirements (copay, coinsurance and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider.
- If the enrollee does not participate, within 14 days of missing the IST, an enrollee is allowed one opportunity to request that another IST become scheduled.
- If the enrollee does not request the rescheduling of the IST within 14 days, or does not participate in a rescheduled IST, the enrollee forfeits the right to have the surprise bill arbitrated, and the Department will notify the enrollee of this fact (and the process ends).
- If either the provider or insurer fails to participate in the IST, the enrollee's request will be referred for arbitration.
- If the IST did not resolve the dispute between the insurer and provider, the Department will work with the insurer and provider to determine the arbitrator that will decide the dispute. The enrollee may decide whether to participate or not participate in the arbitration proceeding. Regardless of whether the enrollee participates in the arbitration proceeding, by virtue of having participated in the IST, the enrollee can only be held responsible for paying the amount of the enrollee's cost-sharing requirements (copay, coinsurance and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider.
- The arbitrator will conduct the arbitration (with or without the enrollee), the arbitrator will determine the amount that the provider is entitled to be paid for the health care services the enrollee was provided, and the arbitrator will provide a final written decision to the enrollee, to the insurer and to the health care provider or authorized representative (and the process ends).