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Surprise Billing Legislation & the Impacts in Georgia for Hospital-Based Pathologists

All across the country we are seeing legislation being passed that limits patient liability where out-of-network services are provided at in-network hospitals. On January 1, 2021, Georgia will enact such legislation. This legislation is referred to as (OCGA 33-20E-2(b) & Prop. Reg. 120-2-106.03). At its core, Surprise Billing legislation aims to eliminate surprise bills, or balance billing, when a patient receives out-of-network (OON) care and must pay the difference between the insurance approved rates and the rate they are charged for their service.

When insured patients are charged for receiving healthcare services from an out-of-network (OON) provider at an in-network facility, the bill that is generated is called a “Surprise Bill.” The law requires consideration of “who” provides the service and “where” the service is provided. The threshold requirements are threefold: (1) the service must be delivered by a “provider;” (2) which is OON; and (3) at an in-network “facility.”

Assuming the hospital is in-network and the physician rendering the professional component is not, this law would apply to limit what the physician can charge.

If the hospital itself is OON, and have non-emergency services, this law should not apply.

For emergency services at an OON hospital, any balance billing, if applicable, would be prohibited by OCGA 33-20E-4(b) & (e) and Prop. Reg. 120-2-106.05(2) & (5).

APS has already begun preparing programming that will identify these OON situations and prevent surprise billing these impacted patients. This will be in place starting with January 1, 2021 dates of service. As always, APS Medical Billing will continue to keep you abreast of new legislation that impacts your business.  

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