Balance Billing

The Guthrie Clinic participates with many different insurance companies. For a complete listing please click here

You may NOT be balanced billed for services, when Guthrie does not participate with your insurance plan in certain circumstances. Non-Guthrie employed providers, are also NOT allowed to balance bill, if they also do not participate with your insurance plan in certain circumstances. For a list of non-Guthrie employed providers, please review the Guthrie Financial Assistance policy. It’s important to understand your rights and responsibilities. Please review “Your Rights” document. What are the new protections? | CMS

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 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 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 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 innetwork 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.

What is Provider-Based Status?

Provider-Based Status is a status sanctioned by Medicare for hospitals and clinics. It is a national model of practice for integrated healthcare delivery systems such as Guthrie Lourdes that includes both hospital and physician offices. In other words, it means that physician offices are departments of the hospital. One of the benefits of having Provider-Based Status is the opportunity to participate in the Federal 340B Drug Purchasing Program.

Will I have to pay an additional fee for my next visit?

Depending on insurance, patients may experience a change in co-pay or co-insurance responsibility. This change will not impact patients covered by Medicaid. Patients will continue to receive bills for the care they receive at Guthrie Lourdes, but charges will be separated to services received from the hospital and those received from providers. This is no different than the way Guthrie Lourdes currently bills for other hospital based services like the Emergency Department, Therapy Services, Lab services and surgical procedures.

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 stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. If your insurance ID card says “fully insured coverage,” you can’t give written consent and give up your protections not to be balance billed for post-stabilization services.

New York State’s Surprise Medical Bills plain language information is available at Surprise Medical Bills | Department of Financial Services (ny.gov) and Pennsylvania has limited information in balance billing plain language requirements.

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 balance 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. If your insurance ID card says “fully insured coverage,” you can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided.

Services referred by your in-network doctor

If your insurance ID card says “fully insured coverage,” surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the Department of Financial Services’ website) for the full balance billing protection to apply.

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 the 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:
- Cover emergency services without requiring you to get approval for services in advance (also known as “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.
- 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, please contact Guthrie’s billing office at 570-887-2600. The federal phone number for information and complaints is: 1-800-985-3059.

Visit No Surprises Act | CMS for more information about your rights under federal law.