Alchemy Therapy, PLLC
4560 Belt Line Road, Suite 404, Addison, TX 75001
972-913-6879
drbodine@alchemydallas.com
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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 copayment, 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 surgical center, certain providers there may be 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 protection 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:
You are only responsible for paying your share of the cost (like the copayments, 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.
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
Notice Concerning Records Requests
Texas law requires that requests for mental health records be in writing. In order to obtain your records, or your child’s records from our practice, please do the following:
To request a copy of your record with our practice, please e-mail your request for records at drbodine@alchemydallas.com. In the subject line, please write “REQUEST FOR RECORDS.” Dr. Bodine will email you a consent form for you to sign to release your records. Please be sure to include the records you want, and the name, address, and/or e-mail address of the intended recipient.
If the records are to be used in litigation, please include case information, such as the cause number, title, and court where the case is pending.
If you need a Business Records Affidavit, please let us know in your request for records. There is a $15 charge for providing a Business Records Affidavit. No Affidavit will be provided unless the fee is paid.
There is a $50 for providing records in this practice. We accept major credit cards. Please note that Texas law does not require us to provide records until the fee is paid.
If you are requesting a copy of couples counseling records, family counseling records, or records for a person who is not yourself or your child, state and federal law require that you provide either a Court Order or an Authorization signed by the person (or parent of the person) whose records you are requesting. 45 C.F.R. §164.512(e); Texas Health & Safety Code §611.004, §611.0045, §611.008.
Instructions for attorneys and document companies:
A subpoena alone is not sufficient to compel the disclosure of confidential counseling and billing records or “Protected Health Information” (PHI) under the Health Insurance Privacy and Portability Act Privacy Rule (HIPAA), 45 C.F.R. Chapter 164.
For medical/hospital/mental health records or information that are requested or subpoenaed in litigation (including court testimony), HIPAA allows a covered entity (such as Alchemy Therapy, PLLC) to disclose PHI in the course of any judicial or administrative proceeding as follows:
In response to an order of a court or administrative tribunal; or
Where the individual (or parent) is a party to the proceeding, he/she knows that the request for his/her PHI has been made, and does not object.
45 C.F.R. §164.512(e). An Authorization from the individual or parent is the kind of document that will satisfy the second option.
NOTE: If the client or parent has indicated that they do not want their records released, a “Statement of Assurance” will not be accepted, and an Authorization or Court Order will be required.
Notice to Concerning Complaints
The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology. Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint. You have a right to have your complaints heard and resolved in a timely manner. If we cannot work things out to your satisfaction, you may file a complaint with my licensing board:
Texas Behavioral Health Executive Council
1801 Congress Avenue, Suite 7.300
Austin, TX 78701
Telephone: 1-800-821-3205
Link to Complaint Form: http://www.bhec.texas.gov/wp-content/uploads/2020/07/BHEC-Complaint-Form.pdf.
Notice Concerning Complains about the Privacy and Security of Your Health Information
If you have a complaint concerning the HIPAA Privacy Regulations, you may contact the U. S. Department of Health and Human Services, Office for Civil Rights, at: OCRMail@hhs.gov.
If you believe that you have a Consumer Complaint regarding the privacy and security of your health information, you may contact the Texas Office of the Attorney General and file a consumer complaint by clicking this link: https://www.texasattorneygeneral.gov/consumer-protection/health-care/patient-privacy