Over the years, we have had numerous clients airlifted from the scene of accidents by air ambulance helicopters only to come home to outrageous bills of $60,000 and $70,000. In recent years, the best policy has been negotiation with the providers but new Georgia and Federal legislation may be changing all of that. Don’t get me wrong, these companies can save your life, but they can also put you in the poorhouse.
So what are the new laws? First let’s review the Georgia Law which became effective on January 1, 2021.
What does it apply to? Any Emergency Medical services.
How does it affect prior authorization and refusal to pay by the insurer?
“Insurers shall pay for covered emergency medical
services for covered persons without prior
authorization and without retrospective denial for
emergency medical services deemed to be medically
necessary.” (Ga. Comp. R. & Reg. 120-2-106-.05(1))
How does it protect against Surprise Bills from Out of Network Providers?
“If a covered person receives emergency medical
services from a non-participating provider, such
person shall not be liable to the non-participating
provider or facility for any amount exceeding the
person’s deductible, coinsurance, copayment, or
other cost-sharing amount as determined by such
person’s policy. (Ga. Comp. R. & Reg. 120-2-106-
.05(2))”
How Does it Deal with the Charges for Out of Network and Lay Out What
The Insurance Should Pay?
“The amount payable by an insurer for emergency
medical services paid directly to the provider shall be
the greater of:
(a) The verifiable median contracted amount paid by
all eligible insurers for similar services calculated by a
vendor utilized and chosen by the OCI Commissioner;
(b) The most recent verifiable amount agreed to by
the insurer and the nonparticipating emergency
medical provider for the same services during which
time the provider was in-network with the insurer; (if
applicable)
(c) A higher amount as the insurer may deem
appropriate given the complexity and circumstances
of the services provided. (Ga. Comp. R. & Reg. 120-2-
106-.05(2))”
Can the Hospital or Air Ambulance Still Balance Bill Me?
No!
“Covered persons are not liable to non-participating
providers or non-participating facilities for any
amount exceeding such person’s cost-sharing
requirement. (Ga. Comp. R. & Reg. 120-2-106-.05(2))”
The Georgia Law overlaps a great deal with the Federal No Surprises Act that went into effect on January 1, 2022>
The Federal Law says:
“If emergency services are provided by a
nonparticipating provider or nonparticipating facility,
coverage for such services must be provided:
-without imposing cost-sharing requirements that
are greater than the requirements that would apply if
the services were provided by a participating provider
or a participating emergency facility. (29 CFR
2590.716-4(b)(3)(ii))”
and when it comes to balance billing:
“Nonparticipating providers and nonparticipating
emergency facilities are prohibited from balance
billing for a payment amount for emergency services
that exceeds the cost-sharing requirement for such
services. (45 CFR 149.410(a))