Collection of Out-of-Network Charges by Healthcare Facility

1. Law
2. Tennessee Code
3. Health, Safety and Environmental Protection
4. Health Facilities and Resources
5. Regulation of Health and Related Facilities
6. Collection of Out-of-Network Charges by Healthcare Facility

1. For the purposes of this section:
   1. “Emergency medical services” means the services used in responding to the perceived individual need for immediate medical care in order to prevent loss of life or aggravation of physiological or psychological illness or injury;
   2. “Healthcare facility” means a hospital as defined in § 68-11-201, or an ambulatory surgical treatment center as defined in § 68-11-201;
   3. “Healthcare provider” means any doctor of medicine, osteopathy, dentistry, chiropractic, podiatry, or optometry; a pharmacist or pharmacy; a hospital; a home health agency; an entity providing infusion therapy services; or an entity providing medical equipment services;
   4. “ln-network healthcare facility” means a healthcare facility that has a current contract provider agreement with the insured's insurer;
   5. “lnsured” means any person who has health insurance coverage as defined in § 56-7-109 through a health insurance entity as defined in § 50-7-109;
   6. “Out-of-network facility-based physician” means a physician:
      1. To whom a participating healthcare facility has granted clinical privileges;
      2. Who provides services to patients of the participating healthcare facility pursuant to those clinical privileges; and
      3. Who does not have a current contract provider agreement with the insured's insurer;
   7. “Stabilized” means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within a reasonable medical probability, to result from or occur during transfer of the individual from a facility; and
   8. “Transfer” means transporting a patient from one (1) location to another for medical services.
2. Healthcare facilities are prohibited from collecting out-of-network charges from an insured, or the insurer on behalf of the insured, in excess of the cost sharing amount required in accordance with the insured's health benefits coverage for the items and services, unless:
   1. The healthcare facility provides written notice to the insured or the insured's personal representative, prior to medical services being provided, that contains the following:
      1. A statement that the insured agrees to receive medical services by the out-of-network facility and will receive a bill for the amount unpaid by the insured's insurer;
      2. A statement that the nonparticipating out-of-network facility-based physician may not have a current contract provider agreement with the insured's insurer and is an out-of-network provider;
      3. A statement that the insured agrees to receive medical services by an out-of-network provider and will receive a bill for the amount unpaid by the insured's insurer;
      4. If the healthcare facility is out-of-network or otherwise a non-participating provider, the estimated amount that the facility will charge the insured for items and services; and
      5. A listing of anesthesiologists, radiologists, emergency room physicians, and pathologists or the groups of such healthcare providers with which the facility has contracted, including the healthcare provider or group name, phone number, and website, along with the following statement:

         The physicians and other healthcare providers that may treat the patient at this facility may not be employed by this facility and may not participate in the patient's insurance network.

         Anesthesiologists, radiologists, emergency room physicians, and pathologists are not employed by this facility. Services provided by those specialists, among others, will be billed separately.

         Before receiving services, the patient should check with his or her insurance carrier to find out if the patient's providers are in-network. Otherwise, the patient may be at risk of higher out-of-network charges.

   2. The insured or the insured's personal representative signs the written notice, acknowledging agreement to receive medical services by an out-of-network provider or should the insured or insured's personal representative refuse to sign the written notice, the healthcare facility documents in the patient's medical record that it provided the notice and that the patient refused to sign the notice.
3. Prior to admission for a scheduled medical procedure, a healthcare facility shall provide the insured with informational materials that include the following:
   1. The estimated amount of copay, deductible, or coinsurance, or range of estimates, that the facility will charge the insured for scheduled items and/or services provided by the facility in accordance with the insured's health benefit coverage for the items and services or as estimated by the insurance company on its website for its insured or through the available information to the facility at the time of prior authorization;
   2. A listing of anesthesiologists, radiologists, emergency room physicians, and pathologists or the groups of such healthcare providers with which the facility is contracted, including the healthcare provider or group name, phone number, and website; and
   3. The following statement:

      The patient will be billed for additional charges, including out-of-network charges, if the patient is provided medical services by a healthcare provider that is not in-network. ln particular, the patient should ask the facility if he or she will be provided any medical services by anesthesiologists, radiologists, emergency room physicians, or pathologists who are not in the patient's network.

4. 1. Except as provided in subdivision (d)(2), the notice required by subdivision (b)(1) must be provided to the insured, or the insured's personal representative, at the time of admission.
   2. 1. lf the insured is receiving medical services through a hospital emergency department and is incapacitated or unconscious at the time of receiving those services, the notice will not be required at that time.
      2. ln circumstances as described in subdivision (d)(2)(A), the written notice required by subdivision (b)(1) must be provided to the insured, or the insured's personal representative, after receiving medical services and within twelve (12) hours following stabilization. Information about a transfer to an in-network facility must also be provided with the written notice.
5. The failure of the healthcare facility to provide the notice required by subdivision (b)(1) and subsection (c) does not give rise to any right of indemnification or private cause of action against the healthcare facility by an out-of-network facility-based physician for an insurer's disregard of an insured's assignment of benefit.
6. When treated at an out-of-network facility, the insured, or the insured's personal representative, must receive the written notice required by subdivision (b)(1) from the facility before being transferred by an ambulance as defined in § 68-140-302 to another facility for treatment of medical services unless the insured would be at risk of bodily injury by the facility giving the insured the notice. The written notice must provide information about the possibility of a transfer to an in-network facility if the in-network facility has similar treatment available and will not risk the insured's health.
7. A bill to an insured from a healthcare provider or healthcare facility must contain a telephone number for the department and a clear and concise statement that the insured may call the department to complain about any out-of-network charges.
8. An in-network healthcare facility does not need to provide an insured with the notice required in subdivision (b)(1)(E) or (c)(3) if the healthcare facility employs all facility-based physicians or requires all facility-based physicians to participate in all of the insurance networks in which the healthcare facility is a participating provider or if the healthcare facility contractually prohibits all facility-based physicians from balance billing patients in excess of the cost sharing amount required in accordance with the insured's health benefits coverage for the items and services provided.

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