Out-of-Network Surprise Bills:

At Hills & Dales Healthcare, we want to protect you from receiving surprise medical bills if you see an out-of-network provider at one of our in-network facilities or emergency services. Hills and Dales Healthcare will only bill you for your insurance plan’s in-network cost share, such as copays and deductibles. Under the No Surprises Act, you have the right to be protected from surprise medical bills in these scenarios.

Surprise or Balance Billing: Your rights and protections against surprise medical bills.

You may owe out-of-pocket costs like a copay, coinsurance, or deductible when seeing a doctor or health care provider. You may also have other costs or may have to pay an entire bill if you see a provider or visit our facility, but our facility is not in your insurance plan’s network.

What is surprise billing (sometimes called balance billing)?

• Surprise billing is when an out-of-network provider bills you for the difference between what your health insurance plan agrees to pay and the total amount charged for a service.
  • Out-of-network means providers and our facility have not signed a contract with your health insurance plan.
• Surprise billing can happen when you can’t control who is involved in your medical care. This includes the following:
  • You have an emergency.
  • You schedule a visit at an in-network facility but are treated by an out-of-network provider without being told ahead of time.
• You are protected from surprise billing or balance billing in certain situations.

When am I protected from surprise billing?

Emergency Services

• You can’t be surprised billed for emergency services. We can only bill you for your health insurance plan’s in-network cost-sharing amount (like copays or coinsurance).
• You also can’t be surprised billed for services you get after you are in stable condition unless you give written consent to be billed for these services.

Non-Emergency Services (out–of–network provider at an in-network facility)

If you receive non-emergency services at our facility that is in-network with your insurance, but the provider is out-of-network:

• The provider or facility can only bill you for your in-network cost-sharing amount (copay/coinsurance) UNLESS you give written consent and give up your protections (see Surprise Billing Protection Form).
• You can’t have a surprised bill for these services if:
  • You cannot choose an in-network provider or
  • You receive services without being told the provider was out-of-network or
  • You receive care from an out-of-network provider at an in-network facility after you have received emergency services.
• You are never required to give up your protection from surprise billing.
• You also aren’t required to receive care from an out-of-network facility. You may choose an in-network provider or facility with your insurance plan.
• Other services at an in-network hospital – certain doctors or healthcare providers - may be out-of-network even though you receive care at an in-network hospital. In these cases, the maximum the providers may bill you is your health insurance plan’s in-network cost-share for:
  • Emergency Room
  • Anesthesia
  • Pathology
  • Radiology
  • Laboratory

What other protections do I have when surprise billing is not allowed?

• You are only responsible to pay your share of the cost (copay, coinsurance, deductible) that you would pay if the provider or facility were in-network. Your health insurance plan will pay out-of-network providers/facilities directly.
• Your health insurance plan generally must:
  • Cover emergency services without approval ahead of time (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility on what it would pay an in-network provider.

Who should I contact if I have questions?

Please reach out to your health insurance company or the Hills and Dales Healthcare billing team at 989-912-6800.