Good Faith Estimate
You have the right to receive a â€œGood Faith Estimateâ€ explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call (800) 985-3059.
Your Rights and Protections Against Surprise Medical Bills
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 and balance billing.
What is â€œbalance billingâ€ (sometimes called â€œsurprise billingâ€)?
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.
â€œOut-of-networkâ€ 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 â€œbalance billing.â€ This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
â€œSurprise billingâ€ is an unexpected balance bill. This can happen when you can’t control who is involved in your careâ€”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:
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 balanced 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 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, email firstname.lastname@example.org for more information about your rights under federal law.
Aspen Mountain Medical Center has adopted an internal grievance procedure that provides for a prompt and equitable resolution of a patient complaint involving patient services or patient care issues while in the Facility. We encourage patients, their representatives or surrogates to first review any issues with the staff present and taking care of the patient at the time of the event or situation or to immediately ask to discuss the situation with the Director of Nursing or Administrator to help resolve matters while the patient is in the Facility.
A grievance is a formal or informal, written or verbal complaint that is made to the Facility by a patient, the patient’s representative, or surrogate when a patient issue cannot be resolved promptly by staff present at the time of the event, issue, or occurrence. Patient grievances also may include messages left by voicemail; sent by email; received by staff calling after a patient is discharged from the Facility; or as part of a patient satisfaction questionnaire. If requested, the Facility can provide a formal â€œPatient Grievance Reportâ€ for completion, but this form is not required to submit a grievance. Grievances may be related to the patient’s care; abuse or neglect; or compliance with federal regulations from the Center for Medicare/Medicaid Services (CMS).
All grievances received by any employee, staff member, or physician will be documented and forwarded to the HIM Director. You may also send them to:
Aspen Mountain Medical Center
Attn: HIM Director
4401 College Drive
Rock Springs, WY 82901
Grievances should be submitted to the Administrator within thirty (30) calendar days of the date of the event. A grievance must contain the name, address, phone # and email contact (if available) of the patient (the â€œgrievantâ€). The information received must state the issue, complaint, concern, or problem to be addressed.
Grievances about situations that endanger the patient, such as neglect or abuse, will be reviewed immediately, given the seriousness of the allegations and the potential for harm to the patient.
Each signed grievance will receive a response within 24 hours, acknowledging receipt of the grievance. This may be done by direct phone contact, email, or mail.
The Administrator will review all information and complete a full investigation, and a written response, action plan or resolution will be issued no later than seven (7) calendar days after receipt of the grievance. If more time is needed for the investigation, the 7-day letter will state the timeline for a final response, no longer than thirty (30) days from the receipt of the grievance.
The grievant may appeal the decision received from the Administrator by filing an appeal in writing, addressed to the â€œFacility Board of Managersâ€ within ten (10) calendar days of receiving the response from the Administration. This appeal must state the elements of dissatisfaction with the response received and further resolution requested.
The Board of Managers will conduct a separate investigation and review and will issue a written decision in response to the appeal within seven (7) calendar days or with an extension of no more than thirty (30) calendar days from receipt of the appeal. This is the same timeframe as provided for the original grievance response. The Administrator will not participate in the review and decision-making process for this appeal.
If a patient has filed a grievance and returns to the Facility for additional care before the grievance is resolved, he/she will not be cared for by the alleged staff member or physician involved in the grievance complaint.
Patients, patient representatives, or surrogates may log a grievance with the U.S. Department of Health and Human Services â€“ directly, regardless of whether he/she has first used the Facility’s grievance process. The Department of Health and Human Services Office for Civil Rights, 999 18th Street, Suite 417, Denver, CO 80202. Voice phone: 1-(800) 368-1019, Fax: (303) 844-2025 or through hhs.gov/ocr/privacy/hipaa/complaints/index.html.
Patients may log a grievance with the Medicare Beneficiary Ombudsman directly, regardless of whether he/she has first used the Facility’s grievance process. Medicare may be contacted at medicare.gov/claims-appeals/your-medicare-rights/get-help-with-your-rights-protections or (800) 633-4227.
Minimal provisions for the Patient’s Bill of Rights:
Aspen Mountain Medical Center adopts and affirms as policy the following rights of patients/clients who receive services from our facility. The Facility will provide the patient, the patient’s representative or surrogate verbal and written notice of such rights in advance of the procedure in accordance with 42 C.F.R. Â§ 416.50 Condition for Coverage- Patient Rights. The patient rights are as follows:
- Treatment without discrimination as to age, race, color, religion, sex, national origin, political belief, or handicap. It is our intention to treat each patient as a unique individual in a manner that recognizes their basic human rights. Treatment without discrimination as to age, race, color, religion, sex, national origin, political belief, or handicap. It is our intention to treat each patient as a unique individual in a manner that recognizes their basic human rights.
- Considerate and respectful care including consideration of psychosocial, spiritual, and cultural variables that influence the perceptions of illness.
- Be free from any act of discrimination or reprisal against the patient merely because he or she has exercised their rights.
- Receive, upon request, the names of physicians directly participating in your care and of all personnel participating in your care.
- Obtain from the person responsible for your health care complete and current information concerning your diagnosis, treatment, and expected outlook in terms you can be reasonably expected to understand. When it is not medically advisable to give such information to you, the information shall be made available to an appropriate person on your behalf.
- The patient may wish to delegate his/her right to make informed decisions to another person, even though the patient is not incapacitated. To the extent permitted by State law, the ASC must respect such delegation.
- Receive information necessary to give informed consent prior to the start of any procedure and/or treatment, except for emergency situations. This information shall include as a minimum an explanation of the specific procedure or treatment itself, its value and significant risks, and an explanation of other appropriate treatment methods, if any.
- The patient may elect to refuse treatment. In this event, the patient must be informed of the medical consequences of this action. In the case of a patient who is mentally incapable of making a rational decision, approval will be obtained from the guardian, next-of-kin, or other person legally entitled to give such approval. The Facility will make every effort to inform the patient of alternative facilities for treatment if we are unable to provide the necessary treatment.
- The Facility will provide the patient or, as appropriate the patient’s representative or surrogate with written information concerning its policies on advance directives, including a description of applicable State health and safety laws and, if requested, official State advance directive forms, if such exist. Access to health care at this Facility will not be conditioned upon the existence of an advance directive.
- You may appoint a patient representative or surrogate to make health decisions on your behalf, to the extent permitted by law.
- Privacy to the extent consistent with adequate medical care. Case discussions, consultation, examination, and treatment are confidential and should be conducted discreetly.
- Privacy and confidentiality of all records pertaining to your treatment, except as otherwise provided by law or third party payment contract.
- A reasonable response to your request for services customarily rendered by the Facility, and consistent with your treatment.
- Expect reasonable continuity of care and to be informed, by the person responsible for your health care, of possible continuing health care requirements following discharge, if any.
- The identity, upon request, of all health care personnel and health care institutions authorized to assist in your treatment.
- Refuse to participate in research or be advised if your personal physician and/or Facility propose to engage in or perform human experimentation affecting his/her care or treatment. Refusal to participate or discontinuation of participation will not compromise the patient’s right to access care, treatment, or services.
- Upon patient request, examine and receive a detailed explanation of your bill including an itemized bill for services received, regardless of sources of payment.
- Know the Facility’s rules and regulations that apply to your conduct as a patient.
- Be advised of the Facility grievance process. The investigation of all grievances made by a patient, the patient’s representative or surrogate regarding treatment of care that is (or fails to be) furnished. Notification of the grievance process includes: who to contact to file a grievance, and that the patient, the patient’s representative or surrogate will be provided with a written notice of the grievance determination that contains the name of the contact person, the steps taken on his or her behalf to investigate the grievance, the results of the grievance, and the grievance completion date.
- Complaints or criticisms will not serve to compromise future access to care at this Facility. Staff will gladly advise you of procedures for registering complaints or to voice grievances including but not limited to grievances regarding treatment or care that is (or fails to be) furnished.
- Access and copy information in the medical record at any time during or after the course of treatment. If patient is incompetent, the record will be made available to his/her representative and/or surrogate.
- Expect to be cared for in a safe setting regarding: patient environmental safety, infection control, security, and freedom from abuse or harassment.
- Receive care free of restraints, unless medically reasonable issues have been accessed and pose a greater health risk without restraints.
- Participate in the development, implementation, and revision of his/her care plan.
Complaints may be directed to (307) 352-8900 or the following State Agency:
Wyoming Department of Health
401 Hathaway Building
Cheyenne, WY 82002
Medicare Beneficiary Ombudsman