Frances Cybenko, MSN, APRN, PMHNP-BC
Soul II Soul Behavioral Health and Medicine LLC
Patient Out-of-Network, No Surprises Act Disclosure
The No Surprises Act protects patients from surprise health care bills in situations where patients have little to no control over who provides their care.
Soul II Soul Behavioral Health and Medicine LLC (“Practice”) operates as an out-of-network, private-pay behavioral health practice. This means the Practice does not bill insurance companies directly. Patients are responsible for payment at the time services are rendered and may choose to submit documentation (such as a superbill) to their insurance provider for possible reimbursement.
Because the Practice is out-of-network with all insurance plans, patients should understand how their insurance benefits may apply before receiving services.
Your Rights and Protections Against Surprise Health Care 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 surprise or balance billing.
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, such as a copayment, coinsurance and/or a deductible. You may have other costs or must 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” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be allowed to bill you for the difference between what your plan agreed to pay 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 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. Examples are 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.
Services at This Practice
Because this Practice is out-of-network with most insurance plans:
The Practice collects payment directly from the patient at the time of service.
The Practice may provide a superbill or itemized receipt that the patient may submit to their insurance company for possible reimbursement.
Insurance reimbursement is not guaranteed and depends entirely on the patient’s insurance plan and benefits. Patients are encouraged to contact their insurance carrier directly to determine whether their plan includes out-of-network behavioral health benefits.
Simple Example of Out-of-Network Reimbursement
Insurance reimbursement can vary depending on the services provided during a visit. This Practice bills based primarily on time; however, the services performed during that time may differ (for example, medication management, therapy-informed interventions, or visits focused primarily on medication review). Insurance companies may reimburse differently based on how they classify the service.
Example: If a session fee is $175, and your insurance plan reimburses 70% of the allowed amount after your deductible:
If your insurance company’s allowed amount is $140:
70% of $140 = $98 reimbursement
Your final cost would be $77 ($175 session fee - $98 reimbursement)
If your deductible has not been met, reimbursement may be lower or delayed until the deductible is satisfied.
Each insurance plan is different. It is the patient’s responsibility to understand their individual benefits.
You are Protected from Balance Billing for:
Emergency services
If you have an emergency health condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments, deductibles and coinsurance. You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
New Jersey’s state law provides similar protections.
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’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 believe you’ve been wrongly billed:
you may send complaints about potential violations of federal law or state law to:
The U.S. Department of Health & Human Services at:
Phone: 800-985-3059
New Jersey Department of Banking & Insurance
Phone: 800-446-7467
Website: https://www.nj.gov/dobi/consumer.htm