No Surprises Act

Emory Healthcare is committed to helping you navigate issues that govern your physical and financial health. There are two new laws that may impact healthcare billing: the Georgia Surprise Billing Consumer Protection Act (a Georgia state law) and the No Surprises Act (a federal law), and their respective implementing regulations. Pursuant to the No Surprises Act, certain disclosures are provided below. Emory Healthcare anticipates additional updates, guidance, and changes throughout 2022 and beyond.

Surprise Billing – Your Rights and Protections Against Surprise Medical Bills

• When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you have protection from surprise billing.
• What is “surprise billing”? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may also have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
• “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
• “Surprise billing” is a balance bill where a patient did not have notice that treatment was being rendered by an out-of-network provider. 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.

You are protected from surprise billing in certain circumstances:

Emergency services. If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent to be balanced billed for these post-stabilization services. The No Surprises Act defines which types of services fall into these categories.

Certain services at an in-network hospital or ambulatory surgical center. When you receive 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 may 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 balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent. You’re never required to give your consent. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

Uninsured/Self-Pay Patients. Some provisions of the No Surprises Act are inapplicable to patients who are uninsured or who are self-pay. Instead, uninsured/self-pay patients are generally entitled to a “good faith estimate” for non-emergency services. Please visit our webpage for more information.

Georgia State Protections. Many of the same protections afforded by the federal law are mirrored in the Georgia state law, but there are some key differences. The Georgia law only applies to self-insured employer health plans and government plans and is limited to services provided in Georgia. In addition to hospitals and ambulatory surgery centers, the Georgia law also applies to certain imaging centers, birthing centers, and similar facilities. Further, Georgia law has a different grievance process and disclosure requirements than the federal law. Definitions under the Georgia law and the federal law, although similar, may not be identical.

If balance billing isn’t allowed:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan is required to pay providers and facilities directly.
• Your health/insurance plan generally must: cover emergency services without requiring approval in advance (prior authorization; cover emergency services by out-of-network providers; 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; and count any amount you pay for emergency services or out-of-network services towards your deductive and out-of-pocket limit.

Surprise Billing – Your Grievance Rights

If you believe you’ve been wrongly billed, first contact the provider that sent you the bill and also your health plan for an explanation. If they can’t resolve your concerns or for more information, you can contact the United States Department of Health and Human Services (https://www.cms.gov/nosurprises) regarding the federal law or the Georgia Office of the Commissioner of Insurance and Fire Safety (https://oci.georgia.gov or call 404-656-2070) regarding the Georgia law.

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Under the Georgia Surprise Billing Consumer Protection Act (a Georgia state law) and the No Surprises Act (a federal law), there may be certain circumstances where Emory Healthcare provides you a notice and consent document (e.g. surgical services, cancer services, long term care services, transplants). This notice and consent document will describe certain non-emergency items or services to be provided by healthcare providers who are out-of-network with your insurance/health plan and will seek your consent to receive that care and permit those providers to bill at out-of-network rates.

Emory Healthcare did not develop the notice and consent document. The notice and consent document is a standard form created by the United States Department of Health and Human Services which healthcare providers are required to use with only minimal modification.

If you are requested to complete a notice and consent document, you are not required to provide your consent. However, the providers are not required to provide the care in the absence of the consent. If you do not provide consent, you may instead choose to seek care from a different provider who may be in-network with your insurer/health plan. We encourage you to reach out to your insurer/health plan to find providers who are in-network. (Emory Healthcare does not have information regarding all providers that may be in-network with your insurance/health plan.) Emory Healthcare seeks to honor a patient’s choice of provider to the greatest extent possible.

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No Surprises Legislation and YOU Good Faith Estimate

Emory Healthcare is committed to helping you navigate issues that govern your physical and financial health. There are two new laws that may impact healthcare billing: the Georgia Surprise Billing Consumer Protection Act (a Georgia state law) and the No Surprises Act (a federal law), and their respective implementing regulations. Pursuant to the No Surprises Act, patients who are uninsured or self-pay are generally entitled to a good faith estimate of costs and services for non-emergency care in most circumstances. Emory Healthcare anticipates additional updates, guidance, and changes throughout 2022 and beyond. Please visit our webpage for our most updated content:

Surprise Billing – Your Right to a Good Faith Estimate

Hospitals and ambulatory surgical centers are required to provide patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services based on information known at the time. This estimate will assist in explaining how much your medical care is anticipated to cost.

Please note that a good faith estimate is an estimate based on information known at the time with respect to anticipated non-emergency items/services. The good faith estimate is not a guarantee that your final costs will match the estimate. This means that the final cost of services may be different than this estimate. Final costs for which you are billed may vary for many reasons, among them are the patient’s medical condition, unknown circumstances or complications, final diagnosis, and recommended treatment ordered by the physician.

• You have the right to receive a good faith estimate for the total expected cost of non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• You can request a good faith estimate at any time by contacting the applicable Emory Healthcare facility. For more information, we encourage you to visit this webpage regularly to check for additional information and updates.
• Different time frames apply with respect to providing you a good faith estimate depending on when/how far in advance your non-emergency care is scheduled. Emory Healthcare endeavors to provide all estimates as soon as practicable.
• Emory Healthcare will request an email address to provide you with a good faith estimate. This is the best and easiest way to receive your estimate. Alternatively, you can request a paper copy be mailed to you or that a paper copy is provided to you when you present for your appointment.
• Emory Healthcare providers are either a part of The Emory Clinic or Emory Specialty Associates. If you are scheduling care at an Emory Healthcare hospital or ambulatory surgery center with a physician or other clinical provider who is not a part of The Emory Clinic or Emory Specialty Associates, Emory Healthcare will make certain efforts to reach out to your non-Emory provider to obtain information regarding the estimated costs associated with the services of that non-Emory provider. However, we may not always be able to obtain such information from your non-Emory provider. We encourage you to follow up with your non-Emory provider directly for a good faith estimate regarding their services.

If you believe you have not been provided a good faith estimate when you were supposed to receive one, first contact the applicable Emory Healthcare facility. If they can’t resolve your concerns or for more information, you can contact the United States Department of Health and Human Services (https://www.cms.gov/nosurprises) regarding the federal law or the Georgia Office of the Commissioner of Insurance and Fire Safety (https://oci.georgia.gov or call 404-656-2070) regarding the Georgia law.

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Key Points:

• The federal No Surprises Billing Act took effect on Jan. 1, 2022. As such, we are providing an overview for all providers, with an emphasis on non-Emory employed providers (not employed by The Emory Clinic or Emory Specialty Associates).
• Under the new legislation, independent physicians (not employed by an Emory entity) are responsible for notices, consents, and other disclosures with respect to their services and billing.
• The out-of-network physician/physician group is responsible for providing and obtaining any notice, consent, and disclosure if desired to bill at out-of-network rates in certain circumstances.
• Patients who are treated at an EHC facility by a non-Emory employed provider should generally direct inquiries regarding billing, rates, and notices/disclosures/consents for physician bills to the physician/physician group who provided the service and billed the patient or patient’s insurance.
• EHC may, in certain circumstances, be required to request cost estimate information from non-Emory providers in order to create a good faith estimate for patients.
• See more detail below.

This overview contains important information for all providers – Emory-employed and non-Emory employed – about notices, consents and other disclosures under the No Surprises Act.

Emory Healthcare values the contributions of all members of the medical staff at our facilities and appreciates your understanding and communication as everyone works through these new legal requirements. If you are a non-Emory employed physician (not employed by The Emory Clinic or Emory Specialty Associates), please take particular care in reading the details outlined below, as there are notices, consents, and other disclosures for which you, rather than Emory Healthcare (EHC), are responsible.

EHC is not responsible for notices, consents, and other disclosures for non-Emory employed physicians (not employed by an EHC entity).

The federal No Surprises Act and its implementing regulations impose various requirements related to notice, consent, and disclosure, among other things, when an out-of-network physician wants to bill at out-of-network rates. Under the law, the out-of-network physician/physician group is responsible for providing and obtaining any notice, consent, and disclosure if desired to bill at out-of-network rates in certain circumstances.

• Several of our EHC facilities (e.g., hospitals and ambulatory surgery centers) have, as part of their medical staff teams, physicians and other clinical providers who are not employed by an EHC entity. Such community providers are credentialed to practice at certain of our facilities/hospitals to varying degrees, but they themselves are not employed by an EHC entity.
• EHC, including without limitation its hospitals, is not responsible for providing or obtaining any notice, consent, or disclosure for or on behalf of any member of a facility’s medical staff except for medical staff members who are employees of The Emory Clinic or Emory Specialty Associates.
• Patients who are treated at an EHC facility by a provider that is not employed by The Emory Clinic or Emory Specialty Associates (i.e., “non-Emory employed providers”) should generally direct inquiries regarding billing, rates, and notices/disclosures/consents for physician bills to the physician/physician group who provided the service and billed the patient or patient’s insurance.

EHC may request cost estimate information from non-Emory employed providers in order to create a good faith estimate for patients.

EHC facilities are, in certain circumstances, required to request from non-Emory employed providers certain cost estimate information as part of EHC creating a good faith estimate for uninsured/self-pay patients. EHC would include such information in the estimate of total costs provided to a patient under 45 C.F.R. 149.610. Non-Emory employed providers remain responsible for their obligations under the regulations and for timely providing this information to EHC.

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