Pennsylvania residents facing problem medical bills have powerful legal recourse that many don't realize exists. Between federal law and Pennsylvania-specific statutes, people across the Commonwealth have tools to fight surprise bills and other unfair billing practices.

Understanding these protections can save you thousands of dollars and prevent medical bills from threatening your financial stability. Here's what every Pennsylvania patient needs to know about medical billing protections and how to use them effectively.

What Is Surprise Billing?

Surprise Billing occurs when a provider seeks payment from a patient for services or charges they did not reasonably know about prior to receiving the services. Types of Surprise Bills include:

Balance Billing: The provider bills an insured patient above the coinsurance and deductible amounts owed under the insurance benefits.

Non-Par @ Par Facility: A non-participating provider renders services while an insured patient is at a participating hospital or facility, and bills the patient above the coinsurance and deductible amounts the patient would have owed under in-network insurance benefits.

Non-Par Emergency: A non-participating provider renders services to treat an emergency medical condition or during an emergency department visit, and bills an insured patient above the coinsurance and deductible amounts the patient would have owed under in-network insurance benefits.

Participating Provider: A participating provider bills an insured patient above the coinsurance and deductible amounts owed under in-network insurance benefits.

Uninsured & No Estimate: A provider bills an uninsured or self-pay patient for services and charges about which it did not inform the patient in advance via a good faith estimate.

Federal Protections: The No Surprises Act

Since January 1, 2022, the federal No Surprises Act has provided protections against surprise billing in specific scenarios for patients across the United States, including those in Pennsylvania. There are protections for insured and uninsured/self-pay patients. Understanding how to resolve medical collections and manage debt from hospitals and providershelps Pennsylvania patients navigate billing disputes.

No Surprises Act Protections for Insured Patients

Emergency Services Protection

If you receive emergency care at a hospital or freestanding emergency center - whether participating or non-participating - providers may not bill you beyond the in-network cost-sharing amount (copay, coinsurance, or deductible) determined by your insurance plan.

This applies to:

• Hospitals and Freestanding Emergency Room facilities
• Physicians and professionals, including emergency medicine physicians
• Ancillary providers (laboratories, imaging centers, etc.)

The hospital or provider cannot balance bill you more than what your insurance deductible, coinsurance, and copayment amounts would be under in-network benefits.

Out-of-Network Providers at In-Network Facilities

If you receive care at a participating hospital or facility, a non-participating provider (including anesthesiologists, radiologists, pathologists, and surgeons) may not bill you beyond the in-network cost-sharing amount (copay, coinsurance, or deductible) determined by your insurance plan, except if:

1. The non-participating provider informed you in advance that it is non-participating;
2. The non-participating provider issues to you a written estimate of what it will bill you; and
3. You provide written consent to the services and estimate at least 72 hours before the service.

Without all three elements, the non-participating provider may not balance bill you beyond your in-network insurance cost sharing amount.

Air Ambulance Protection

The No Surprises Act also protects against balance billing for air ambulance services (helicopter or airplane). Air ambulance services may only bill you for the in-network cost-sharing responsibility determined by your insurance plan, even if the air ambulance service is non-participating.

No Surprises Act Protections for Uninsured and Self-Pay Patients

Providers must give patients a Good Faith Estimate (GFE) of services and prices in clear and understandable language. Patients do not have to request a Good Faith Estimate. Providers must issue GFEs within the following timelines.

Advance Scheduling of Services

>=10 days

3 days after scheduling

3-9 days

GFE Deadline

1 day after scheduling

Patient Request

3 days after request

A Good Faith Estimate must include the following:

• Patient name and identifying information
• The primary service or procedure
• An itemized list of all services and supplies
• Service codes, diagnosis codes and prices to be billed
• Names and identifying information of all providers that will bill for services
• A disclaimer that there may be additional items or services as part of the course of care that must be scheduled or requested separately and are not reflected in the Good Faith Estimate
• A disclaimer that the information in the GFE is only an estimate regarding items or services reasonably expected to be furnished at the time the GFE is issued, and that actual items, services, or charges may differ from the GFE
• A disclaimer that the GFE is not a contract and does not require the patient to obtain the items or services from any of the providers or facilities identified in the GFE

How Patient Fairness Helps Pennsylvania Patients

Medical billing protections for Pennsylvanians can be powerful - but only if you know how to use them. Patient Fairness specializes in helping Pennsylvania patients by:

Identifying All Applicable Protections

We analyze your Pennsylvania bill against:

• Federal No Surprises Act protections
• Federal hospital price transparency requirements
• Basic principles of billing fairness and reasonableness
• Scores of other criteria

Many bills contain several different issues, creating multiple grounds for dispute.

Comparing Charges to Fair Benchmarks

We compare the medical bill's charges to:

• Medicare rates for the same services
• A hospital's estimated cost and profit under its bill

Creating Professional Dispute Letters

We draft customized letters that:

• Cite specific and detailed issues and concerns for the dispute, including Pennsylvania statutes and federal law, when applicable
• Inform the provider that you do not intend to pay the bill until the provider reasonably addresses to your satisfaction your concerns under the dispute
• Demand corrections
• Create thorough documentation of your dispute and related communications with the provider

Guiding You Through the Dispute Process

Patient Fairness uses a structured and guided program that customers can easily follow, from assessing the bill and issuing the Letter of Dispute, to pricing analysis and settlement agreements.

Starting at just $49, Pennsylvania residents get professional tools and expertise applied to their specific situation - at a fraction of what billing advocates and other services charge.

Common Provider Responses and How to Counter Them

Providers often use standard responses when patients challenge balance bills. Here's how to respond:

"You signed a consent form agreeing to pay all charges"

Response: Billing protections under the No Surprises Act and Pennsylvania law cannot be nullified in most situations, even with a patient's written consent.

These physician specialties may never have their patients waive No Surprises Act protections: assistant surgeons, hospitalists, and intensivists. These physician specialties and provider types may not have their patients waive No Surprises Act protections related to emergency services: emergency medicine, anesthesiology, pathology, radiology, neonatology, and diagnostic services.

In some cases, a non-participating provider may require a patient to confirm that the patient is electing to see a non-participating provider, is agreeing to pay the non-participating provider more than the cost-sharing responsibility determined by the insurance plan, and is waiving surprise billing protections. In these cases, the waiver of billing protections is only valid if the patient signs it in advance of services, and it includes:

• An estimate of what the patient will pay
• Information about protections from surprise medical bills
• The option to give up those protections and pay more for out-of-network care
• For post-stabilization care: A list of in-network providers at the facility that can provide needed items or services

"We're out-of-network, so we can charge whatever we want"

Response: Not participating in an insurance network doesn't mean providers can disregard your rights as a consumer and patient. Federal and Pennsylvania law restrict out-of-network balance billing in numerous scenarios. Cite the specific law that applies to your situation.

Understanding surprise medical bills helps Pennsylvania patients effectively challenge improper charges.

Sample Results for Pennsylvania Patients

Pennsylvania patients who understand and use their balance billing protections can achieve significant savings:

Philadelphia emergency room case: A patient received emergency treatment at a participating in-network hospital from a non-participating emergency physician and radiologist. Combined balance bills totaled $15,000. After citing the No Surprises Act, all charges were reduced to the patient's in-network deductible of $1,200 - a savings of $13,800.

Pittsburgh surgery case: A patient underwent outpatient surgery at an in-network facility. An out-of-network anesthesiologist billed $5,800 beyond insurance payments. After the patient disputed the bill and cited the No Surprises Act, the anesthesiologist reduced the bill to $175, the coinsurance amount applicable under in-network insurance benefits - a savings of $5,625.

Harrisburg uninsured patient case: An uninsured patient received care and was billed $19,000. After applying for charity care under 40 Pa. Stat. § 115 and demonstrating financial need, the hospital granted 65% financial assistance - reducing the bill to $6,650, which was further negotiated to $4,200 using Medicare rate benchmarks.

These outcomes can happen because the patient disputes the bill based on established consumer protections and other rational arguments.

Don't Pay More Than Pennsylvania Law Requires

Pennsylvania patients face aggressive medical billing, but state and federal law provides powerful protections. Pennsylvanians have multiple tools to fight unfair medical bills. The key is knowing your rights and acting quickly.

Dispute your problem medical bill with Patient Fairness today.

We'll analyze your bill against federal and Pennsylvania patient and consumer protections, identify potential violations and other reasons to dispute the bill, and provide simple processes and professional tools to dispute the bill effectively.

For Pennsylvania patients, understanding balance billing protections isn't optional - it's essential to avoiding thousands of dollars in charges you don't legally owe.

Patient Fairness specializes in helping Pennsylvania patients challenge unfair medical bills. Our flat-fee service, starting at just $49, provides professional dispute tools at a price every patient can afford.