Surprise billing occurs when a patient receives a balance bill after unknowingly receiving care from an out-of-network provider or an out-of-network facility, such as a hospital. This can occur in emergency and non-emergency situations.

At this time, Oklahoma has not enacted protections for consumers against surprise billing. Beginning January 1, 2022, Federal law provides new consumer protections discussed below.

A new federal law, the No Surprises Act, protects you from:

• emergency out-of-network medical bills including air ambulances, and
• non-emergency services at an in-network facility.

It applies to self-insured health plans offered by employers as well as health insurance companies that offer fully insured individual and group plans.

• A facility (such as a hospital or freestanding emergency room (ER)) or a provider (such as a doctor) may not bill you more than your in-network cost sharing amount for emergency services, without requiring prior authorization. 

This is true even if the emergency services you received were at an out-of-network facility or performed by an out-of-network provider.

• Under your health plan, you are still responsible for cost sharing amounts that may include copays, coinsurance, and deductibles. 
• You are also protected when you receive non-emergency services from out-of-network providers at in-network facilities. An out-of-network provider may not bill you more than your in-network co-pay, co-insurance, or deductible for services performed at an in-network facility.
  • You can still consent in advance to receive care from an out-of-network provider in some situations and agree to pay the provider amounts above your in-network co-pay, co-insurance, or deductible.

• You must receive notice of your rights prior to treatment under the new law from your health plan and from the facilities and providers that serve you.
• If you think the protections have not been applied correctly, you can file an appeal with your insurance company or request external review of the company’s decision.
• You can also file a complaint with the Federal Department of Health and Human Services.
• An independent dispute resolution (IDR) process is available for providers and insurance companies to settle disputes about your bill without putting you in the middle. IDR is also available for individuals who are uninsured, in certain circumstances.
• Other protections in the new law require insurance companies to keep their provider directories updated and to limit your co-pays, co-insurance, or deductible to in-network amounts if you rely on inaccurate information in a provider directory.
• NSA exempts Short Term Limited Duration Insurance from compliance as well as excepted benefits, health reimbursement arrangements or other account-based plans and retiree only plans.

The No Surprises Act applies not only to fully insured individual and group health insurance plans offered by health insurers, but also to all group health plans offered by employers. This includes Fully-Insured and Self-Funded Grandfathered plans, Grandmothered Plans (or Transitional), Student health insurance plans, non-federal governmental plans (state, county, city plans) and church plans (MEWA/Association).

Health plans will be held accountable in meeting compliance requirements under the No Surprises Act that includes member notice requirements, Advanced Explanation of Benefits, up-to-date provider directories and continuity of care provisions.

Providers are required to provide a written explanation of the No Surprises Act and its requirements to both the public and to the patient. This includes certain written notices and consent forms that provide a good faith estimate of the cost of services in advance of treatment.

Health plans and providers are required to resolve payment disputes and to protect the insured and patient from a balance or surprise bill through an independent dispute resolution process if required.