Pennsylvania IDR Arbitration For Medical Revenue Recovery

Pennsylvania Surprise Billing Law (SBL)

Pennsylvania has not enacted a state-specific Surprise Billing Law (SBL) to govern out-of-network payment disputes or balance billing practices for healthcare services. As a result, the federal No Surprises Act (NSA), effective January 1, 2022, applies to address surprise billing issues in Pennsylvania.

Under the federal No Surprises Act:

1. Protection Against Surprise Billing: Patients cannot be balance billed for emergency services, certain non-emergency services at in-network facilities, or services provided by nonparticipating providers during visits to in-network facilities.
2. Out-of-Network Payment Disputes: Disputes over out-of-network payments are resolved through the federal Independent Dispute Resolution (IDR) process, as Pennsylvania does not have an All-Payer Model Agreement or applicable state law to override the federal process.
3. Transparency Requirements: Providers and health plans must offer clear cost estimates and disclose patient protections against balance billing.

The NSA ensures that patients in Pennsylvania are shielded from unexpected medical bills and provides a standardized mechanism for resolving disputes between insurers and providers over out-of-network charges.

This approach promotes fairness and protects Pennsylvania residents from financial burdens arising from unforeseen out-of-network care.