Pennsylvania Surprise Billing Law

Overview

Pennsylvania Act 112 (effective 1/1/2021) protects patients from surprise bills when they receive emergency services or unplanned out-of-network care at in-network facilities. Providers cannot charge patients the difference between their fees and in-network rates. Disputes are resolved through baseball arbitration with the Pennsylvania Insurance Department.

Key Requirements

1. Patients receiving emergency services at any facility are protected from balance bills regardless of provider in-network status.
2. Patients receiving unplanned OON services at in-network facilities receive in-network rate protections.
3. Providers must disclose balance billing rights in writing within 30 days of the bill.
4. Facilities must include the EOB and fee schedule information with patient bills.
5. Patients may dispute bills with the insurer or request PA Insurance Department arbitration.

Penalties and Enforcement

Providers violating Act 112 face administrative fines and license discipline. Insurers who fail to arbitrate or comply with awards face penalties and license sanctions. The PA Insurance Department investigates complaints and compels payment when violations occur. Repeat violators face escalating penalties and potential license revocation.

Appeals and Exceptions

Surprise billing protections apply to emergencies and unplanned services. Elective out-of-network care scheduled in advance is not protected. Federal NSA rules provide similar coverage for emergencies. Baseball arbitration decisions are binding.

Interaction with Federal Law

Pennsylvania Act 112 complements the federal No Surprises Act. Both protect emergency services. Pennsylvania extends to non-emergency OON services at in-network facilities, which NSA does not. Patients receive the benefit of the more protective standard. State and federal law work together to prevent surprise billing.

Common Questions