When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing 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, or a deductible. You may have other costs or have to 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 providers may be permitted 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.
You are protected from balance billing for:
Emergency services
If you have an emergency medical 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. You can't be balance billed for these emergency services.
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 may bill you is your plan's in-network cost-sharing amount.
When balance billing isn't allowed, you also have these protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network).
- Your health plan generally must cover emergency services without requiring you to get approval for services in advance.
- Your health plan must base what you owe the provider or facility on what it would pay an in-network provider or facility.
- Your health plan must count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you've been wrongly billed, you may contact the U.S. Department of Health and Human Services at 1-800-985-3059.
Visit cms.gov/nosurprises for more information about your rights under federal law.
Billing Questions
If you have questions about an Oregon ENT Center bill, please contact our billing department at (541) 779-7372.