Surprise medical bill: what you can be charged out of network

The "surprise bill" is the one that arrives when the hospital was in your network but the anaesthesiologist, pathologist or radiologist were not, or when the emergency gave you no choice. Chapter 48 attacks it from two sides: with caps on what you can be charged and with prior disclosure duties. One definition in the chapter does a lot of work: "knowingly, voluntarily and specifically selected an out-of-network provider" means you chose that provider with full knowledge they were out of your network, when you had the opportunity to be seen by one in network. And the text adds the safeguard: a provider merely disclosing their network status does not by itself make your decision to proceed with treatment a "knowing" choice.

Anyone covered by a health plan subject to the Code. There is an exception that changes the outcome and is worth identifying before arguing: if your coverage is administered by an entity running a self-funded health plan and that plan did not elect to be subject to Article 48.080, then the provider may indeed bill you above the applicable deductible, copay or coinsurance. To be bound, the self-funded plan must notify the Office of the Insurance Commissioner annually, on the form it prescribes, certifying its participation and agreeing to be bound. If you do not know which kind of plan you have, that is the first question for your insurer.

Information pending verification.

Information pending verification.

1. 1

   Step 1: Before an elective appointment, demand the three disclosures

   Article 48.030 requires the facility, before scheduling an appointment for a non-emergency procedure, to tell you in terms an average person can understand: whether the facility is in or out of your plan’s network; that you should check with the physician arranging the services whether they are in or out, with information on how to determine which plans any physician reasonably expected to treat you participates in; and what each scenario means for your wallet. The facility must also publish on its website the plans it participates in, a warning that physicians’ services are not included in its charges, and — where applicable — the name, address and phone of the physician groups it contracted with for anaesthesiology, pathology and radiology.

2. 2

   Step 2: In an emergency, the cap is the in-network one

   This is the rule that settles most cases. If you received medically necessary services at any facility on an emergency or urgent basis — as defined in the federal Emergency Medical Treatment and Active Labor Act — the facility shall not bill you above any deductible, copay or coinsurance applicable to in-network services under your plan. Neither shall the health professional. If the bill that arrived exceeds that, it is exactly what the chapter prohibits.

3. 3

   Step 3: Do not sign anything that turns you into a "knowing choice"

   The protection is lost if you knowingly, voluntarily and specifically selected an out-of-network provider. But the law sets a high bar: that means you chose that provider with full knowledge they were out of network, when you had the opportunity to be seen by one in network. And it clarifies that mere disclosure of network status does not by itself turn your decision to proceed into a "knowing" choice. A paper handed to you on a gurney is not the same as an informed choice with a real alternative.

4. 4

   Step 4: Let the dispute run between them

   Article 48.080 assigns the benefits to the out-of-network provider with no action required from you: the reimbursement is paid directly to them, and the insurer must give them in writing a remittance specifying the proposed reimbursement and the deductible, copay or coinsurance amounts you owe. If the insurer considers the billed amount excessive, it has thirty (30) days from receiving the bill to say so and to offer a payment proportional to what an in-network provider receives for the same services. Then there are another thirty (30) days to negotiate. If there is no agreement, the insurer pays its final offer.

5. 5

   Step 5: If they still disagree, you may start the arbitration yourself

   When the insurer and the provider cannot agree on a final offer as reimbursement, the chapter says the insurer, the provider or the covered person — as applicable — may start an arbitration proceeding within thirty (30) days of the final offer, under Articles 48.090 and 48.100. That the covered person is named there matters: you do not depend on either of them making the first move.

6. 6

   Step 6: Report the improper charge

   Article 48.030 itself says it as part of what the facility must tell you: any bill, charge or collection attempt by the facility or any professional involved that exceeds your copay, deductible or coinsurance, in violation of these rules, must be reported to the pertinent regulatory entity. For insurers, that entity is the Office of the Insurance Commissioner; for patient rights, the Office of the Patient Advocate receives claims.

The Office of the Insurance Commissioner regulates insurers and the self-funded plans that elect to be bound by Article 48.080. The Office of the Patient Advocate receives patient rights claims. And there is a useful fact buried in the chapter: every facility with an in-network contract shall report annually to the Health Department the plans it has those agreements with, and that information shall be available to the Office of the Insurance Commissioner.

• Looking for the rules in Act 134-2020: its substantive section is "omitted" and lives in Chapter 48 of the Health Insurance Code.
• Paying an emergency bill above the copay, deductible or coinsurance that would apply in network.
• Believing that signing a network-status form makes you a "knowing choice": the law expressly says mere disclosure is not enough.
• Not asking, before an elective appointment, whether the physician arranging the services is in your network even if the facility is.
• Waiting for the insurer or provider to start the arbitration: the covered person may start it too.
• Not checking whether your plan is self-funded and whether it elected to be bound by Article 48.080, which is where the protection may not apply.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov

• Office of the Insurance Commissioner

  OCS

  ocs.pr.gov

• File your claim — Patient Advocate

  OPP

  www.opp.pr.gov