Surprise Medical Bills and the No Surprises Act

Getting a bill for thousands of dollars from a doctor you never chose is one of the most frustrating experiences in the American health system. Since January 1, 2022, the federal No Surprises Act has banned many of these bills for people with insurance. But the law has gaps, and people who do not know their rights end up paying anyway. This guide explains what is protected, what is not, and what to do if you get a bill that looks wrong.

What counts as a surprise bill

A surprise bill, or balance bill, arises when a provider outside your insurance network charges you the difference between their bill and what your insurance pays. It typically happens in situations where you have little say in who treats you, for example:

• You go to an in-network emergency room, but the doctor who treats you is out of network.
• You have a planned surgery at an in-network hospital, but the anesthesiologist, assistant surgeon, radiologist or pathologist is out of network.
• You need an emergency air ambulance transport and the provider is out of network.

What the No Surprises Act protects

For people with most private health insurance (employer plans, Marketplace plans and others subject to the rules), the law requires the following:

1. Emergency services must be covered without prior authorization, and out-of-network emergency providers and facilities cannot bill you more than the in-network cost-sharing amount. This applies until you are stable, and in some cases afterward if you cannot travel.
2. Non-emergency services by out-of-network providers at in-network facilities (hospitals, hospital outpatient departments, and ambulatory surgical centers) are protected for most services. You pay in-network cost sharing, and the provider cannot balance bill you. The cost sharing counts toward your deductible and out-of-pocket maximum as if the provider were in network.
3. Air ambulance services from out-of-network providers are protected in the same way.
4. The exception: some out-of-network providers can ask you to give up the protections by signing a notice and consent form, but that is not allowed for emergency care, or for certain ancillary providers such as anesthesiologists, radiologists, pathologists or assistant surgeons, or when the provider is at an in-network facility and no in-network provider is available.

The insurer and the provider work out the payment between themselves, using an independent dispute resolution process if they disagree. You should not be asked to participate.

What is not covered

• Ground ambulances. The federal law does not cover ground ambulance rides, although some states have their own protections.
• Planned care that you choose out of network. If you pick an out-of-network provider for a non-emergency service, you can be billed more.
• Services not covered by your plan. The law protects against balance billing, not against the cost of services your plan excludes.
• Some plans. Medicare, Medicaid and TRICARE have their own rules limiting balance billing. Short-term plans and some other plans may not be covered in the same way.

Your rights as an uninsured or self-pay patient

If you do not have insurance, or are not using it, providers and facilities must give you a good faith estimate of the expected cost of non-emergency care when you schedule it, if it is scheduled at least three business days ahead, and when you ask for it. If the final bill is at least $400 higher than the estimate from any provider or facility, you can use a federal patient-provider dispute resolution process, but you must start it within 120 days of the bill.

How to avoid problems before care

1. Ask which providers will be involved and whether each of them is in network, including the facility.
2. Get the estimate and plan details in writing when you can, and note the name and date of anyone who confirms in-network status over the phone.
3. Check that the plan has given you prior authorization when it is required.
4. If you have a choice, schedule the procedure at an in-network facility.
5. Before you sign a form at a hospital, read it. If it says you are giving up balance billing protections for a provider, you can refuse, especially for emergency or ancillary services.

What to do if you get a surprise bill

1. Do not pay right away. Wait for the Explanation of Benefits (EOB) from your insurer, which shows what was billed, what the plan paid and what you owe.
2. Compare the bill with the EOB. If the provider has billed you more than the EOB says you owe, call the provider and cite the No Surprises Act.
3. Call your insurer and ask them to reprocess the claim as protected under the law, if you believe it applies.
4. File a complaint with the federal No Surprises Help Desk at 1-800-985-3059 or through CMS, or with your state insurance department.
5. Keep records: bills, EOBs, the dates and names for each call, and the written responses.

In-network does not mean in-network for everyone

Networks change, and a provider who was in network at the beginning of the year might leave. The law has some continuity-of-care protections for people in treatment when a provider leaves a network. If this is happening, ask your insurer what transition period you have. When you choose a plan in open enrollment, take the time to check the network and pay attention to the plan types in our HMO vs PPO guide.

Keeping a paper trail

Most bills that are wrong stay wrong because patients cannot show what they were told. When you schedule a procedure, write down the date, the name of the person you spoke with, and what they said about network status and cost. Save emails and portal messages. After the procedure, wait for the Explanation of Benefits, compare it with the provider’s bill, and ask for an itemized bill with billing codes. If a collection agency contacts you about a disputed bill, ask for validation of the debt in writing. You can also check whether the hospital offers financial assistance, which can reduce or eliminate a bill, even if you have insurance. Many people find that a calm, documented call, naming the law, is enough to correct the problem.