Tennessee Surprise Billing Protections

Overview

Tennessee HB 748/SB 692 (effective July 1, 2020) provides surprise billing protection for emergency care. The federal No Surprises Act (effective January 1, 2022) expands protections to scheduled non-emergency services at in-network facilities provided by out-of-network (OON) providers. Patients are protected from unexpected balance bills in both scenarios, paying only in-network cost-sharing amounts.

Key Requirements

1. Emergency Care Standard: Patients pay in-network cost-sharing for emergency care regardless of provider network status. OON emergency providers cannot balance bill patients above in-network rates.
2. Scheduled Services at In-Network Facilities: OON providers cannot balance bill patients for scheduled services at in-network facilities unless the patient has signed 72-hour advance written consent.
3. Good Faith Estimates: Providers must supply written cost estimates for scheduled services before treatment, allowing patients to make informed decisions about in-network vs. OON options.
4. Payment Dispute Process: Provider and insurer disputes are resolved through the federal Independent Dispute Resolution (IDR) process, not passed to the patient.
5. Self-Funded Plan Coverage: ERISA self-funded employer plans are subject to the federal No Surprises Act and the federal IDR process.

Penalties and Enforcement

Violations of surprise billing protections by insurers or providers are enforced by the Tennessee Department of Commerce and Insurance (state-regulated plans) or the Centers for Medicare and Medicaid Services (ERISA plans). Violations include failing to adjust claims to in-network rates, refusing to apply federal NSA protections, or failing to provide Good Faith Estimates. Violators are required to refund improperly billed amounts to patients and may face civil penalties.

Appeals and Exceptions

Patients have the right to appeal any claim determination related to surprise billing. The primary exception is advance written consent: if a patient signs a 72-hour advance consent form for OON services at a non-facility location, they may be charged OON rates. Emergency care has no exception. Post-stabilization services are covered by the federal NSA and cannot be balance billed.

Interaction with Federal Law

The federal No Surprises Act applies to all health plans nationwide, including ERISA self-funded plans exempt from state insurance regulation. For state-regulated plans, both Tennessee state law and federal law apply; the strongest protection governs. CMS enforces the federal NSA for ERISA plans; TDCI enforces state law and federal NSA for state-regulated plans.

Common Questions