The medical billing laws in Indiana are governed by the federal No Surprises Act and the state-specific legislation, House Enrolled Act 1238 (HEA 1238). Here are the detailed guidelines and laws:Federal No Surprises Act

1. Balance Billing Prohibitions:
   • Emergency Services: Out-of-network providers and facilities are prohibited from balance billing for emergency services, including further examination and treatment.
   • Non-Emergency Services: Balance billing is prohibited for non-emergency services when rendered in a participating facility, such as a hospital outpatient department, critical access hospital, or ambulatory surgery center.
2. Good Faith Estimates (GFEs):
   • Federal Requirements: The federal No Surprises Act requires providers to provide a GFE to patients for scheduled appointments and upon request. The GFE must include the expected items and services, the estimated charges, and the payment methods accepted.
   • Indiana Requirements: Until the federal GFE and advance explanation of benefits requirements are fully implemented, Indiana providers and facilities should continue to follow the state law requirement to provide a GFE to covered individuals (excluding Medicaid recipients) for ordered, scheduled, or referred non-emergency services.
3. Out-of-Network Reimbursement:
   • Qualified Payment Amount (QPA): The QPA is determined by finding the median of the contracted rates recognized by the health plan on January 31, 2019, for the same or similar item or service, provided by a provider in the same or similar specialty, in the same geographic region, and increased annually for inflation.
   • Payment Process: The health plan is responsible for establishing the QPA and stating it in their initial payment or denial for an out-of-network item or service. The patient's in-network cost-share obligation is applied to the QPA to determine their cost-share responsibility.

Indiana House Enrolled Act 1238 (HEA 1238)

1. Compliance with Federal Requirements:
   • Effective Date: HEA 1238 amended relevant Indiana code provisions to state that healthcare practitioners and facilities can satisfy the Indiana-specific balance billing and good faith estimate requirements by complying with the requirements of the federal No Surprises Act, effective July 1, 2022.
2. State Law Requirements:
   • Balance Billing: HEA 1238 prohibits balance billing for out-of-network services, but it does not explicitly exempt providers and facilities who comply with the federal law from also complying with certain, more restrictive, requirements in Indiana law.
3. Definitions:
   • Definitions of "Practitioner," "Provider," "Facility," and "Provider Facility": These definitions differ between the federal and state laws, which could result in differing interpretations and potentially, legal challenges in the future.

Additional Requirements

1. Patient-Provider Dispute Process:
   • Uninsured and Self-Pay Patients: The patient-provider dispute process for uninsured and self-pay patients includes a notice form that must be provided to the patient at least 5 business days in advance of the service. The form must include a consent form, which the patient must sign and return to the provider prior to the provision of the service.
2. Disclosure Requirements:
   • Disclosure Form: A model disclosure form developed by CMS has been adapted for Indiana-specific requirements. The disclosure must include information on the restrictions on providers and facilities regarding balance billing, applicable state law protections against balance billing, and contact information for state and federal agencies.
3. Notice and Consent:
   • Notice Form: A template form is provided for notice and consent to balance billing. The form must be signed and returned by the patient prior to the provision of the service. A copy of the signed consent must be provided to the patient and the health plan.
4. CMS Forms:
   • Model Notice Form: A model notice form is provided for "Your Rights and Protections Against Surprise Medical Bills." This form includes a consent form and must be provided to the patient in person, by mail, or by email.
5. Toolkit for Compliance:
   • Surprise Billing Laws Toolkit: The Indiana Hospital Association (IHA) has developed a toolkit to assist providers in complying with the federal and state requirements. The toolkit includes template documents that can be adapted by hospitals to assist in complying with current state and federal requirements.

Key Points

• Balance Billing: Balance billing is prohibited for emergency services and non-emergency services rendered in participating facilities.
• Good Faith Estimates: Providers must provide GFEs for scheduled appointments and upon request.
• Out-of-Network Reimbursement: The QPA is used to determine the out-of-network rate, and the patient's in-network cost-share obligation is applied to the QPA to determine their cost-share responsibility.
• Compliance: Providers and facilities must comply with both federal and state requirements to ensure compliance with the No Surprises Act and HEA 1238.

References

• WNDU: New Indiana Law Aims to Reduce 'Surprise' Medical Bills
• IHA Toolkit for Compliance with Surprise Billing Laws
• IHA Toolkit for Compliance with Surprise Billing Laws (November 2021)

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