Michigan law prohibits ‘surprise billing’

As of Oct. 22, 2020, Michigan state law prohibits surprise billing by nonparticipating professional providers in Michigan for emergency services and some non-emergency services provided on and after this date. Participating providers already agree not to balance bill our members.

“Surprise billing” refers to instances where a member unknowingly receives care from a nonparticipating provider and later receives an unexpected bill for the difference between the insurer’s payment and what the provider charges.

Nonparticipating professional providers in Michigan will no longer be able to balance bill members in the following scenarios outlined in the law:

• Covered emergency services at a participating or nonparticipating health facility
• Covered non-emergency services at a participating health facility when at least one of the following events occurs:
• The patient doesn’t have the ability or opportunity to choose a participating provider; or
• The nonparticipating provider doesn’t provide the required advanced written disclosure notice to the member of the service’s estimated costs and notice of the right to seek care from a participating provider (see Public Act 235)
• A health care service at a participating health facility for a patient who was admitted to the hospital within 72 hours after receiving a health care service in the hospital’s emergency room

For the above scenarios, the law defines the benchmark rate that these nonparticipating providers must now accept as payment in full. The benchmark rate is defined as the greater of the following (excluding any in-network cost share):

• The median amount negotiated by the patient’s carrier for the region and provider specialty, or
• 150% of the Medicare fee-for-service amount listed on the fee schedule for the health care service provided 

Members are responsible for any in-network cost-sharing requirements.

If you have questions, contact Provider Inquiry at the appropriate number below:

• Blue Cross Blue Shield of Michigan
  • Physicians and other professional providers of care: 1-800-344-8525
  • Hospital and facility providers: 1-800-249-5103
• Blue Care Network
  • Professional providers: 1-800-344-8525
  • Ancillary and facility providers:1-800-249-5103