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Janice C. C. Lepore, Psy.D. and Associates, LLC

A practice specializing in assessment and consultation services for children, adolescents and young adults.

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  • No Surprises Act Disclosure

No Surprises Act Disclosure

On January 1, 2022, new regulations became active regarding the federal No Surprises Act (NSA). The original intent of the NSA, as we understand it, was to protect against ‘surprise’ billing when patients seek emergency care, and/or seek care at in-network facilities, but unexpectedly receive treatment from out-of-network providers.

While the NSA  would not seem to address outpatient out-of-network practices such as ours, at this time the wording of the regulations is unclear. We are including here information on the No Surprises Act, and related consumer rights/resources. If you have any questions about this information, or about our billing practices or fees, please feel free to contact your clinician.

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 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 are 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.

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.

You are never required to give up your protections from balance billing. You also are not 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 are 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:

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 have been wrongly billed,  The federal phone number for information and complaints is: 1-800-985-3059.

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

 

 

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P (443) 912-1230   F (410) 823-0215

1400 Front Ave #204, Lutherville-Timonium, MD 21093

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