Pennsylvania Balance Billing Law

Overview

Pennsylvania Act 112 (2020) prohibits balance billing for emergency services and unplanned out-of-network care at in-network facilities. Providers cannot charge patients the difference between their fee and the insurer's payment. Disputes are resolved through baseball arbitration with the Pennsylvania Insurance Department.

Key Requirements

1. Patients at in-network facilities receiving emergency services from OON providers are protected from balance bills.
2. Unplanned OON services at in-network facilities must be billed at in-network rates.
3. Patients must receive written notice of balance billing rights within 30 days of the bill.
4. Providers must file arbitration requests within 60 days of claim denial or payment.
5. Baseball arbitration: each party submits one proposed fee, arbitrator selects one in full.

Penalties and Enforcement

Providers who balance bill in violation of Act 112 face penalties from the PA Insurance Department and license discipline. Insurers who fail to honor arbitration awards face fines and sanctions. The Department investigates complaints and compels compliance. Repeat violators face escalating penalties and potential license revocation.

Appeals and Exceptions

Balance billing protections do not apply to elective out-of-network services chosen by the patient. Emergencies and unplanned care at in-network facilities are protected regardless of provider in-network status. Federal NSA standards provide overlapping coverage. Arbitration awards are binding on both parties.

Interaction with Federal Law

Pennsylvania Act 112 is as protective or more protective than the federal No Surprises Act. Both cover emergency services at all facilities. Pennsylvania extends to planned OON services at in-network facilities. When state and federal law conflict, the more protective standard applies.

Common Questions