New Billing Requirements

September 15, 2015

Memorandum

On August 24, 2015, Governor Rauner signed HB 3848 into law. Now known as Public Act 99-0454, this new law, effective January 1, 2016, amends the Sexual Assault Survivors Emergency Treatment Act to:

  • Clarify the prohibition on directly billing any sexual assault survivor;
  • Require hospitals to issue survivors a notice regarding billing and a payment authorization voucher; and
  • Require health care professionals who are not employed by a hospital or hospital affiliate and who bill separately to submit a billing protocol to the Office of the Illinois Attorney General. 

Background

Through the Illinois Criminal Justice Information Authority (ICJIA), Illinois receives federal grant funds for programs that assist sexual assault survivors, including the Sexual Assault Nurse Examiner (SANE) program in the Office of the Illinois Attorney General (OAG). To receive these funds, ICJIA must certify that no sexual assault survivor is directly billed for hospital emergency services and forensic services. HB3848 amends the Sexual Assault Survivors Emergency Treatment Act (SASETA) to:

  • Clarify the prohibition on directly billing a sexual assault survivor for hospital emergency services or forensic services;
  • Provide direction on the appropriate entity to bill;
  • Require treatment hospitals to give survivors a written notice related to billing;
  • Require treatment hospitals to provide an Authorization for Payment Voucher (voucher) for follow-up treatment to eligible survivors; and
  • Prohibit healthcare professionals (e.g., physicians, APNs and others) who are not employed by a hospital or hospital affiliate and who bill separately for hospital emergency services or forensic services from directly billing a sexual assault survivor for the services and require these health care professionals to submit a billing protocol to the OAG for approval.

Prohibition on Direct Billing of a Sexual Assault Survivor

SASETA prohibits direct billing of a survivor for hospital emergency services and forensic services as defined below:

“Hospital emergency services” means healthcare delivered to outpatients within or under the care and supervision of personnel working in a designated emergency department of a hospital, including, but not limited to, care ordered by such personnel for a sexual assault survivor in the emergency department.

“Forensic services” means the collection of evidence pursuant to a statewide sexual assault evidence collection program administered by the Department of State Police, using the Illinois State Police Sexual Assault Evidence Collection Kit.

A hospital, healthcare professional, ambulance provider, laboratory or pharmacy furnishing hospital emergency services, forensic services, transportation, follow-up healthcare or medication to a sexual assault survivor shall not:

  • Charge or submit a bill for any portion of the costs of the services, transportation or medication to the survivor, including any insurance deductible, co-pay, co-insurance, denial of claim by an insurer, spenddown or any other out-of-pocket expense;
  • Communicate with the survivor about payment;
  • Refer the bill to collection;
  • Provide information to affect the survivor’s credit rating; or
  • Take any other action adverse to the survivor or her or his family.

Note that the prohibition does NOT include bills for inpatient services. Hospitals and other providers may directly bill a survivor or any applicable insurance for inpatient services.

Appropriate Billing

A hospital or healthcare professional providing hospital emergency services and forensic services, an ambulance provider furnishing transportation to a survivor, a hospital, healthcare professional or laboratory providing follow-up services, or a pharmacy dispensing prescribed medications to any survivor shall furnish such services or medications to that person without charge and seek payment as follows:

(1) If the survivor is eligible for Medicaid, submit the bill to the Department of Healthcare and Family Services or the appropriate Medicaid Managed Care Organization and accept the amount paid as payment in full.

(2) If the survivor is covered by a policy of health insurance or is a beneficiary under a public or private health coverage program, bill the insurance company or program. Applicable deductible, co-pay or other out-of-pocket insurance-related expenses may be submitted to the Illinois Sexual Assault Emergency Treatment Program for payment at allowable rates under the Public Aid Code. Providers must accept the amounts paid by the insurance company or health coverage program and the Illinois Sexual Assault Treatment Program as full payment.

(3) If the survivor is neither eligible for Medicaid nor covered by insurance or a health coverage program, submit the request for reimbursement to the Illinois Sexual Assault Treatment Program at the allowable rates under the Public Aid Code.

(4) If a survivor presents a voucher for follow-up healthcare, lab or pharmacy services, bill the Illinois Sexual Assault Emergency Treatment Program for payment at allowable rates under the Public Aid Code. If the survivor has insurance, the provider must first bill insurance as primary, then send a bill for any remaining balance, along with a copy of the voucher, to the Illinois Sexual Assault Emergency Treatment Program for payment at allowable rates under the Public Aid Code. Providers must accept the amounts paid by the insurance company and the Illinois Sexual Assault Treatment Program as full payment.

To submit a claim to the Illinois Sexual Assault Emergency Treatment Program, a hospital must complete a UB-04 hospital claim. Other providers can use any other claim form, as long as it is an actual “claim” and not a billing statement. An HCFA 1500 will be accepted.

To submit the claim, mail; scan and email; or fax the claim as follows:

Mail to HFS Illinois Sexual Assault Emergency Treatment Program, PO Box 19129, Springfield, Il, 62794-9124
Fax to (217) 558-1317

Requirements for Treatment Hospitals

Provide written notice about billing: By March 1, 2016, (60 days after the Act’s effective date), every hospital providing treatment services to sexual assault survivors in accordance with a Plan approved by the Illinois Department of Public Health shall provide written notice to sexual assault survivors that includes certain information related to billing. 

Note: Transfer hospitals are not required to provide these notices to survivors about billing.

Provide vouchers: Effective January 1, 2016, every hospital providing treatment to a survivor is required to:

  • Issue a voucher to any survivor eligible to receive one;
  • Give the voucher to the survivor;
  • Place a copy in the survivor’s medical record; and
  • Provide an additional copy to the survivor after discharge, upon request. 

Eligible survivors are those who are not covered by Medicaid. For eligible survivors with a voucher, the Illinois Sexual Assault Treatment Program will cover follow-up care and medications related to the sexual assault that are provided within 90 days of the initial emergency department visit. 

The survivor must submit the voucher to the follow-up provider, as the voucher contains instructions for billing. After a patient’s primary insurance is billed, any remaining balance should be billed to the Sexual Assault Treatment Program. Providers are reimbursed at the allowable rate under the Public Aid Code.

In order to provide a voucher, a hospital must register with the MEDI system of the Department of Healthcare and Family Services. 

Note: Transfer hospitals are not required to provide vouchers to survivors.

Requirements for Healthcare Professionals Not Employed by the Hospital

Healthcare Professional Billing Protocol: By March 1, 2016, healthcare professionals (e.g., physicians, APNs and others) who are not employed by the hospital or a hospital affiliate and bill separately from the hospital for hospital emergency services or forensic services must develop a billing protocol that ensures that no survivor of sexual assault will be sent a bill for these services, and submit the billing protocol to the Crime Victim Services Division of the Office of the Attorney General for approval. 

Healthcare professionals who bill as a legal entity may submit a single billing protocol for the billing entity. Healthcare professionals who bill separately from the hospital should refer to Section 7.5 of the Act for the required contents of this protocol. The Office of the Illinois Attorney General has indicated it will provide a sample protocol for this purpose. 

Note: The above requirement does NOT apply to healthcare professionals employed by hospitals, hospital affiliates (as defined by the Hospital Licensing Act) or those employed by a hospital operated under the University of Illinois Hospital Act.

Penalties

The following penalties apply to hospitals and healthcare professionals. The OAG may assess $500 per violation for willful violations or a pattern or practice involving the following actions:

  • Directly billing a survivor for hospital emergency services or forensic services;
  • Communicating with or harassing the survivor for payment;
  • Contacting or distributing information to affect the survivor’s credit rating;
  • Taking an action adverse to the survivor or his or her family on account of providing services to the survivor; or
  • Hospital’s failure to provide the written notice to survivors required by the Act.

The OAG may assess a penalty of $500 for each day that a survivor’s bill is with a collection agency.

The following penalties apply to healthcare professionals required to submit a billing protocol to the OAG for approval. The OAG may assess $100 per day on a healthcare professional who fails to submit a billing protocol as required under Section 7.5 (d) of the Act, until the healthcare professional complies with the requirements. 

Sample Written Notice to Survivors

PA99-0454 requires treatment hospitals to provide a notice containing specific information about billing to each sexual assault survivor. A sample written notice that meets the requirements of the new law is available.. 

Note: Hospitals must include the telephone number of the contact at their facility whom the survivor should call should he/she receive a bill from the hospital for hospital emergency services or forensic services.

Instructions for Generating the Required Online Voucher

The Illinois Department of Healthcare and Family Services administers the Sexual Assault Emergency Treatment Program to reimburse providers when a sexual assault survivor is neither covered by an insurance policy nor has Medicaid. The voucher must be generated and provided to a survivor at the time of the emergency visit. 

To generate an online voucher, a hospital must be registered with the MEDI system. Instructions on registering with MEDI and for generating a voucher for a survivor. 

Elective Hospital Billing Protocol Template

Although PA99-0454 does NOT require hospitals to develop a billing protocol, IHA has drafted a template for an elective hospital billing protocol that hospitals may choose to use or customize for their individual organizations.