The No Surprises Act, enacted on January 1, 2022, is a significant piece of legislation aimed at protecting patients from unexpected medical bills also known as “surprise billing”. These unexpected charges can create a significant financial burden for patients. While the Act applies to most types of health insurances, it also extends protections to self-pay patients, such as Zion HealthShare members.
It is important to know your rights and protections as you seek care. Zion HealthShare members are encouraged to understand and utilize the protections of the No Surprises Act, especially the requirement for good faith estimates.
Your Right to a Good Faith Estimate
As part of the No Surprises Act, healthcare providers and facilities are generally required to provide a “good faith estimate” to self-pay or non-insured patients prior to a scheduled appointment. This estimate is a written document that outlines the expected charges for the service. Providers must give these estimates upon request or at least three business days before the service. A typical good faith estimate includes:
- A list of expected charges for items or services by the provider or facility.
- Details about each item or service, including healthcare service codes.
For example, if you are scheduled for surgery, the estimate might include the cost of the surgery itself, anesthesia, and any necessary lab tests. However, it may not cover items or services scheduled separately, like pre-surgery appointments or post- surgery physical therapy. Separate estimates will be provided for these additional services if you schedule an appointment or request an estimate.
If you receive a bill that is $400 or more above the good faith estimate, you may be able to dispute the bill. Please note, good faith estimates will not be provided during emergency care.
Limitations and Dispute Resolution
While the No Surprises Act provides significant protections, it is important to note it does not regulate or set the cost of healthcare services. The Act addresses unexpected charges and provides transparency but does not control or cap prices.
Good faith estimates are based on anticipated costs and may not cover all potential charges that arise during treatment. However, if you receive a final bill that exceeds the good faith estimate by $400 or more, you have the right to dispute these discrepancies.
Steps for Disputing Charges
- Negotiate with the Provider: Start by contacting the provider’s billing department to discuss the discrepancy. Reference the good faith estimates and try to resolve the issue directly.
- Formal Dispute Resolution: If negotiation does not resolve the issue, you can submit a formal dispute. This must be done within 120 days of the billing date. During this process, the provider or facility cannot:
- Move your bill to collections or threaten to do so.
- Collect existing late fees on the unpaid bill.
- Take any negative action against you for disputing the bill.
*If your bill is already in collection, collection efforts must be halted until the dispute is resolved.
For additional support and resources on how to dispute a bill, visit the Centers for Medicare & Medicaid Services: Dispute a Bill
Zion HealthShare & the No Surprises Act
As members of Zion HealthShare, it is important to understand how the No Surprises Act impacts your healthcare experience:
- Always Request a Good Faith Estimate: When scheduling medical services, ask for a detailed cost estimate to avoid unexpected charges. Use this estimate to compare prices and make informed decisions about your healthcare options.
- Inquire About Discounted Rates: Based on the provider or facility, self-pay or non-insured patients may be eligible for discounted rates. These rates may be offered under different categories as designated by the provider. Common named discounts include: self-pay, cash-pay, prompt pay, or pay in full. Ask your provider or facility to apply all available discounts.
- Understand Your Rights: Familiarize yourself with the protections offered by the No Surprises Act to ensure you are not overcharged.
- Use the Dispute Resolution Process: If you receive a bill that seems excessively high compared to the estimate, use the dispute resolution process to challenge the charges.
- Communicate with Providers: Clearly communicate your self-pay status with providers and ensure they understand your billing preferences to avoid confusion.
How to Present as a Self-Pay Patient
How to Present as a Self-Pay Patient
Zion HealthShare and Self-Pay
Zion HealthShare is not insurance; if you do not have another health insurance provider, you should present as a self-pay patient when seeking services from your provider. This will allow for the appropriate application of self-pay discounts, as most providers tend to offer these discounts automatically upon being informed. These discounts allow us to keep membership contributions low.
To avoid any confusion, we kindly ask that you refrain from presenting your Zion HealthShare membership card to the providers. Providers will assume Zion HealthShare is insurance and try to bill us directly. We cannot accept claims from providers as we are not insurance. You should obtain itemized bills and receipts to request payment or reimbursement from the Zion HealthShare community. In some cases, prepayment may be an option.
If you are also covered by any relevant insurers, third-party administrators, or government assistance plans, please do not present as self-pay. These plans will be the primary payor, and Zion HealthShare will be secondary.
*Official Member Guideline
Insurance, Third-Party Administrators, & Government Assistance Plans
If you have other insurance, a group plan, or government assistance, or the like, those will be responsible for covering your medical expenses first. The Zion HealthShare community will only step in to share any remaining eligible medical expenses. If you've hired a lawyer to handle medical expenses related to a specific need or because of issues with medical services, Zion HealthShare will wait to see the outcome of your case before deciding if the community can share any leftover eligible medical expenses.
It's important to let us know if you have any other coverage, including through a spouse, family member, employer, or government program. If you don’t disclose this information, your expenses may not be eligible for sharing.
Before Your Appointment
Look for providers who accept self-pay patients. Some clinics or providers may offer discounts or have special rates for self-pay patients. Zion HealthShare provides a complimentary Medical Advocacy service to assist you in finding providers that accept self-pay patients.
Request Medical Advocacy
As a valued member of Zion HealthShare, we provide a complimentary Medical Advocacy service to assist you in finding reasonably priced medical providers for your upcoming medical needs. Our team of specialists is available to schedule payment arrangements in advance. You may contact them at 888-399-0017 or email advocacy@zionhealthshare.org for assistance.
When scheduling your appointment, clearly state that you are a self-pay patient. This will help ensure a smoother process for sharing. Additionally, ask about any available self-pay discounts they may offer. Being transparent about your payment status can also open the door to discussing the cost of services and exploring affordable options. For some services, request an estimate of the costs for the services you expect to receive in advance.
At the Appointment
When you arrive, remind the front desk staff or billing department that you are a self-pay patient. Please be sure to request itemized receipts for all services provided.
After the Appointment
Once you receive your bill, please carefully review it to ensure there are no errors. While billing errors are rare, they do happen. If you notice an error on your bill, call your provider to request the error be corrected before submitting any bills to Zion HealthShare.
Once you have an accurate bill, submit all documents to your member portal under your open sharing request.
If you have not opened a sharing request for this medical need, please do so as soon as possible. For more information on submitting a sharing request, visit How to Submit a Sharing Request.
Member Guideline Notice
Notice
Please note all article sections formatted like this are official member guidelines and will be marked “*Official Member Guideline” when applicable. Anything else is simply helpful information to assist you in understanding the member guidelines and how to use your Zion HealthShare Membership.
Members who call the Zion HealthShare office asking about eligibility of medical expenses will be given an opinion, not a decision. Sharing Requests and medical expenses cannot be authorized over phone. For more information on submitting bills to Zion HealthShare, review the Member Guidelines or login to your Member Portal.
These guidelines are effective as of January 1, 2025.
Note
The Member Guidelines that go into effect January 1, 2025 will only be applicable to sharing requests that are submitted on or after that date. If a sharing request was submitted prior to January 1, 2025 the sharing request will be reviewed for sharing eligibility according to the Member Guidelines in effect at that time.
How To Utilize Medical Advocacy
How to Utilize Medical Advocacy
What Is Medical Advocacy?
Medical Advocacy is a service complimentary to all Zion HealthShare members. Our team of experts is here to help members find fair-cost providers and facilities in your area. The Medical Advocacy team is available to assist you with gathering good faith estimates for upcoming procedures, advocating for self-pay discounts, arranging pre-payments, and facilitating payment for therapy services after procedures. Review this video for an overview of Medical Advocacy:
What Does Medical Advocacy Do?
Our Medical Advocacy team goes beyond simply answering questions. Services offered by the Medical Advocacy team:
- Find Fair-Cost Providers: Since Zion HealthShare isn’t part of a traditional network, you have the freedom to choose any provider. The Advocacy team can help you find providers who meet your family’s needs and offer competitive rates, saving you and the community money.
- Cost Transparency: Need an upcoming procedure? We can help you gather good faith estimates beforehand, allowing you to make informed decisions.
- Prepayment Assistance: For eligible sharing requests, the Advocacy team can arrange pre-payments to help with upfront costs.
- Surgical Procedure Coordination: The Medical Advocacy team offers added support in coordinating surgical procedures.
- Member Guideline Assistance: Many members discover the intricacies of our guidelines when facing a medical need. The Advocacy team can help you understand the relevant guidelines applicable to your specific situation and walk you through the next steps of your sharing request.
Request Medical Advocacy
Zion HealthShare offers a straightforward process for accessing Medical Advocacy services through our member portal. Here’s how to get started:
- Log in to your Zion HealthShare Member Portal: Access the portal with your login and password.
- Submit a Sharing Request: Navigate to the sharing request section and provide details about your medical need.
- Indicate Your Need for Support: Within the sharing request form, you’ll find a question asking, “Do you need help locating a provider that offers fair rates for self—pay patients?”
- Select “Yes” for support: Choosing “Yes” connects you with the Medical Advocacy team. They’ll reach out shortly to discuss your needs and help you find suitable providers.
- Pre-payment Inquiry: For some medical services, the sharing request form may ask if pre-payment is required. You can select “Yes”, or “No/Unsure” based on your situation.
Alternative Contact Methods
If you prefer, you can also request assistance from our Medical Advocacy team using the following contact information:
Phone Number: 888-399-0017
Email Address: Advocacy@zionhealthshare.org
Medical Advocacy is available M-F: 8-4pm MST
In non-emergency situations, we recommend you contact Zion HealthShare before receiving a medical service.
*If you are experiencing an emergency, please seek immediate care. You are not required to contact Zion HealthShare prior to receiving medical treatment.
Member Guideline Notice
Notice
Please note all article sections formatted like this are official member guidelines and will be marked “*Official Member Guideline” when applicable. Anything else is simply helpful information to assist you in understanding the member guidelines and how to use your Zion HealthShare Membership.
Members who call the Zion HealthShare office asking about eligibility of medical expenses will be given an opinion, not a decision. Sharing Requests and medical expenses cannot be authorized over phone. For more information on submitting bills to Zion HealthShare, review the Member Guidelines or login to your Member Portal.
These guidelines are effective as of January 1, 2025.
Note
The Member Guidelines that go into effect January 1, 2025 will only be applicable to sharing requests that are submitted on or after that date. If a sharing request was submitted prior to January 1, 2025 the sharing request will be reviewed for sharing eligibility according to the Member Guidelines in effect at that time.
Additional Resources
For assistance or more detailed information about the No Surprises Act please refer to these resources or reach out to Zion HealthShare at 888-399-0017:
- Centers for Medicare & Medicaid Services: The No Suprises Act
Member Guideline Notice
Notice
Please note all article sections formatted like this are official member guidelines and will be marked “*Official Member Guideline” when applicable. Anything else is simply helpful information to assist you in understanding the member guidelines and how to use your Zion HealthShare Membership.
Members who call the Zion HealthShare office asking about eligibility of medical expenses will be given an opinion, not a decision. Sharing Requests and medical expenses cannot be authorized over phone. For more information on submitting bills to Zion HealthShare, review the Member Guidelines or login to your Member Portal.
These guidelines are effective as of January 1, 2025.
Note
The Member Guidelines that go into effect January 1, 2025 will only be applicable to sharing requests that are submitted on or after that date. If a sharing request was submitted prior to January 1, 2025 the sharing request will be reviewed for sharing eligibility according to the Member Guidelines in effect at that time.