Priority Health - NEW MI Legislation Prohibits Out-of-Network Providers from Sending Surprise Bills to Patients

March 1, 2021

On Oct. 22, 2020, Governor Whitmer signed two bills (Public Act No. 234 and No. 235) into law that forbid out-of-network PARE providers from sending surprise bills to patients. Surprise billing, or balance billing, has never been allowed for our participating providers.

 

What’s changing for providers

Under the new law, out-of-network PARE providers are now required to give disclosures ahead of providing service to non-emergency patients, and aren’t allowed to balance bill patients in emergency scenarios.  If the provider fails to give the disclosure of if the member does not sign, the provider cannot balance bill the member.  If approved or signed, the patient may be balance billed.

 

Out-of-network providers are required to give the following to non-emergency patients:

  • A statement that the patient’s insurer may not cover all services 
  • A “good-faith” estimate for services 
  • A statement that patients may request care from an in-network provider 
  • An acknowledgement of understanding signed by the patient or their representative that the provider has provided the member with a disclosure form and cost estimate at least 14 days in advance of the service. The form, if signed by the member, would allow the member to be balance billed.

 

How this impacts claims for out-of-network providers

With the result of the new legislation, effective Mar. 1, 2021, out-of-network providers who submit clams to Priority Health will be paid 150% of what Medicare pays or the median amount for the medical service, whichever is greater. In emergency situations, or if a provider fails to give the required disclosures, the provider cannot balance bill the member.