Jeffrey Wade
A surprise medical bill is an unexpected bill from an out-of-network provider or facility. The No Surprises Act, which came into effect in 2022, protects people covered under group and individual health plans from receiving such bills when they receive emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. The act also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for the uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.
| Characteristics | Values |
|---|---|
| Definition | An unexpected bill from an out-of-network provider or facility |
| Protection | The No Surprises Act may protect you from surprise medical bills under certain circumstances |
| Protection for insured patients | If you have health insurance and your health plan denies all or part of a claim for service, you can appeal that decision |
| Protection for uninsured patients | If you are uninsured or self-pay for insurance, you should receive a good faith estimate of costs for your care from your provider when you either schedule that care or if you call and request the estimate |
| Protection for insured patients in New York | Consumers with health insurance coverage provided by an insurer or HMO are protected from surprise bills when a participating doctor refers them to a non-participating provider |
| Protection for insured patients in California | California law protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility, and receive care from an out-of-network provider without their consent |
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What You'll Learn
The No Surprises Act
A surprise medical bill is an unexpected bill from an out-of-network provider or facility. This can happen when a patient cannot choose who is involved in their care—for example, during an emergency or when they schedule a visit at an in-network facility but are unknowingly treated by an out-of-network provider.
The NSA establishes an independent dispute resolution process for payment disputes between plans and providers. It also provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider. If you are uninsured or self-pay for insurance, you should receive a good faith estimate of costs for your care from your provider when you schedule that care or if you call and request the estimate. After receiving care, if you are billed for an amount more than $400 over the good faith estimate and you received the bill within the last 120 calendar days, you can use the new dispute resolution process to determine the final payment amount.
The NSA supplements state surprise billing laws; it does not replace them. The Act creates a "floor" for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibilities for patients. The NSA also contains provisions such as cost-sharing rules, prohibitions on balance billing for certain services, notice and consent requirements, and requirements related to disclosures about balance billing protections.
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Protections for insured and uninsured
The No Surprises Act, which came into effect on January 1, 2022, offers protections for insured and uninsured individuals against surprise medical bills. A surprise medical bill is an unexpected bill from an out-of-network provider or facility.
Protections for the insured
If you have health insurance and receive a surprise medical bill, the No Surprises Act may protect you from paying the full amount. The Act bans surprise bills for most emergency services, even if they are received out-of-network and without prior authorization. It also bans out-of-network cost-sharing for most emergency and some non-emergency services, meaning you cannot be charged more than the in-network cost-sharing amount for these services. Additionally, the Act bans out-of-network charges and balance bills for certain additional services, such as anesthesiology or radiology, provided by out-of-network providers as part of a patient's visit to an in-network facility.
If your health plan denies all or part of a claim for service, you have the right to appeal that decision. Your plan documents will contain information on the review process and how to request a review of your plan's decision.
Protections for the uninsured
If you are uninsured, you are also protected against surprise medical bills under the No Surprises Act. Starting on January 1, 2022, you should receive a good faith estimate of the costs for your care from your provider when you schedule that care or if you call and request the estimate. If you receive a bill that is more than $400 over the good faith estimate within 120 calendar days, you can use the new dispute resolution process to determine the final payment amount. This process involves a third-party arbitrator who will review the good faith estimate, the final bill, and any other relevant information submitted by your provider or facility.
In addition to federal protections, some states, such as New York and Washington, have their own laws and dispute resolution processes to protect consumers from surprise medical bills. For example, in New York, if you are uninsured and receive a bill for emergency services that you believe is excessive, you can file a dispute through the state's independent dispute resolution process.
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Surprise bill dispute process
Surprise billing occurs when an individual with health insurance coverage receives care from an out-of-network provider or an out-of-network facility, resulting in higher costs than expected. To address this issue, the No Surprises Act was established, providing protections against surprise medical bills for individuals with specific health insurance coverage, such as Medicare, Medicaid, or TRICARE.
The Act also outlines a dispute resolution process for surprise bills, which can be summarised in the following steps:
Step 1: Understand Your Coverage and Protections
Before seeking care, it is essential to understand the protections offered by your health insurance plan. The No Surprises Act applies to individuals with group or individual health plans, protecting them from surprise bills for most emergency services and specific non-emergency services from out-of-network providers at in-network facilities. Additionally, it covers services from out-of-network air ambulance service providers.
Step 2: Obtain a Good Faith Estimate
If you are uninsured or self-pay, you should receive a good faith estimate of the expected charges for your care before receiving treatment. This estimate serves as a baseline for potential dispute resolution later.
Step 3: Review Your Bill
After receiving care, carefully review the bill to identify any discrepancies or unexpected charges. Compare the billed amount to the good faith estimate to determine if there is a significant difference.
Step 4: Initiate the Dispute Process
If you identify a discrepancy, you can initiate the dispute process. The specific process may vary depending on your state and insurance plan. Contact your health insurance provider or visit the CMS No Surprises Act website to understand the applicable dispute resolution process.
Step 5: Submit a Dispute
If eligible, submit a dispute through the appropriate channel, such as the Federal patient-provider dispute resolution process or your state's Independent Dispute Resolution (IDR) process. You may need to complete and submit an IDR Patient Application form, providing relevant documentation and information.
Step 6: Await the Decision
An independent reviewer or arbitrator will assess the good faith estimate, the final bill, and any other relevant information to make a decision. This process ensures a fair resolution, determining the final payment amount.
It is important to note that there may be specific time frames and eligibility requirements for initiating a dispute, such as filing the dispute within 120 days of receiving the bill. Additionally, certain states, like New York, have their own dispute resolution processes that may apply instead of the federal process.
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Surprise bills and emergency services
A surprise medical bill is an unexpected bill from an out-of-network provider or facility. The No Surprises Act (NSA) protects insured patients from surprise medical bills under certain circumstances. The Act supplements state surprise billing laws, creating a "floor" for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibilities.
The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers. Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills.
If you get health coverage through your employer, a Health Insurance Marketplace, or an individual health insurance plan you purchase directly from an insurance company, the No Surprises Act will ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization). It will also ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services. In addition, the Act bans out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
In New York, consumers are protected from surprise bills when treated by an out-of-network provider at a participating hospital or ambulatory surgical center in their health plan’s network. Consumers with health insurance coverage provided by an insurer or HMO are also protected from surprise bills when a participating doctor refers them to a non-participating provider. Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment.
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Balance billing
Prior to 2022, it was common for people to be balance billed in emergencies or by out-of-network providers working at in-network hospitals. This could be extremely costly for patients, especially if their insurance did not cover out-of-network care at all.
In the United States, balance billing usually occurs when a patient receives care from a healthcare provider or hospital that is not part of their health insurance company's provider network or does not accept Medicare or Medicaid rates as payment in full. If a healthcare provider has opted out of Medicare entirely, the patient is responsible for paying the entire bill themselves. However, if the provider has not opted out but does not accept the amount Medicare pays as payment in full, the patient could be balance billed up to 15% more than Medicare's allowable charge, in addition to their regular deductible and/or coinsurance payment.
To protect consumers from balance billing, federal legislation was enacted in 2022 as part of the Consolidated Appropriations Act, 2021. The No Surprises Act, which is incorporated into this legislation, protects people covered under group and individual health plans from receiving surprise medical bills in most cases. It also establishes an independent dispute resolution process for payment disputes between plans and providers and provides new dispute resolution opportunities for uninsured and self-pay individuals.
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Frequently asked questions
A surprise medical bill is an unexpected bill from an out-of-network provider or facility.
The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes.
If you receive a surprise medical bill, you're not responsible for paying it. Your insurer must pay the out-of-network provider and facility directly. You are only responsible for your in-network cost-sharing, including any copays, coinsurance, and deductible.
