Your Rights & Protections Against Medical Bills

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a co-payment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgery center there may be providers who are out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost.

You are only responsible for paying your share of the cost (like the co-payments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact 1-800-985-3059.
Visit www.cms.gov/nosurprises for more information about your rights under federal law.

Prairie Lakes Healthcare System offers a wide range of medical services for people who call northeastern South Dakota and western Minnesota home.

View Services

Feel good about your skin’s health. Our specialists offer individualized treatment plans and cosmetic options.

Learn More

Learn More

When you're ready, we're ready with prenatal and childbirth education, all-in-one birthing suites, one-to-one nursing, and breastfeeding support.

Learn More

The American Cancer Society recommends those at average risk* for colorectal cancer to start regular screenings at age 45. A colonoscopy doesn’t take a lot of time, but this simple procedure offers a big payback: peace of mind. Colorectal cancer is deadly, but treatable if it’s caught early. The majority of colonoscopic exams turn up no lesions at all, and in many other cases polyps and other suspicious growths can be removed during the colonoscopy.

A colonoscopy is an endoscopic examination of the rectum, colon and part of the small intestine. A tiny camera on the end of a long flexible tube, lets the doctor perform a non-surgical, real-time examination of your colon.

The entire procedure takes little more than a couple of hours. The biggest challenge is the preparation beforehand, and it’s important to follow the prep directions carefully. Sedation or anesthesia ensures that the process is painless. You wake up a short time later, and you’re soon ready to go home.

*According to the American Cancer Society, people are considered to be at average risk if they do not have:

• A personal history of colorectal cancer or certain types of polyps
• A family history of colorectal cancer
• A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
• A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC)
• A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer

Save time and money with a Direct Access Colonoscopy

Quick and easy interview to see if you qualify.

If you qualify for a Direct Access Colonoscopy a consultation clinic visit is not needed, saving you time and money. Please fill out the form below or call the General Surgery Clinic at 882-6852 for a phone interview to see if you qualify for a Direct Access Colonoscopy.

Need a Colonoscopy?

Please complete the form below and a nurse will contact you.