How the No Surprises Act protects you against surprise medical bills

January 11, 2022 in Health finance  •  By Miles Varn, MD
surprise medical bills

Surprise medical bills can cause significant financial and mental stress, with some bills totaling in the thousands of dollars. These types of bills are so common and hard to understand that Kaiser Health News and NPR have an ongoing monthly feature called “Bill of the Month, where they investigate bills submitted by readers.

What are surprise medical bills?

The term refers to bills that people receive for care they unknowingly receive from providers outside their insurance network. The most common situations where people receive these unexpected bills are when seeking care for an emergency or receiving care in the hospital. For example, the hospital emergency department where you received care may be part of your network, but the radiologist who performed your CT scan or the anesthesiologist who provided your epidural were not in-network providers, which can leave you with a large bill you have to pay out of pocket.

Surprise medical bills affect approximately 1 in 5 emergency care claims and 1 in 6 in-network hospital care claims for people with private health insurance, according to data from the Kaiser Family Foundation. The U.S. Office of Health Policy found that surprise medical bills averaged more than $1,200 for anesthesia, $2,600 for surgical assistants, and $750 for childbirth. Those costs can be especially difficult for people with high deductible health plans who are already paying a significant amount out of pocket for their care.

A new law, the No Surprises Act, which went into effect on January 1, 2022, is designed to protect people with health insurance from these bills. It covers emergency care at hospital emergency departments, free-standing emergency departments, and urgent care centers that are licensed to provide emergency care; non-emergency care from out-of-network providers at in-network facilities; and air ambulance services from out-of-network providers. Ground ambulance services, a frequent source of surprise bills, are not covered by the current law, but there is an advisory committee working on ways to address these bills.

Under the law, healthcare providers are not allowed to bill patients more than what they would pay if they received these services from an in-network provider. Before the act was passed, providers could bill patients their full fee, then the patient had to submit a claim to their insurer to be reimbursed for whatever amount their plan covered for the care.

Now, providers must submit any surprise bills directly to the patient’s health insurer. The insurer will work with the provider to determine the covered cost and alert the patient if they owe any copay, coinsurance, or deductible for the service. If the insurer and provider can’t negotiate a price, an independent arbiter will determine what the fair reimbursement from the insurer is.

Patients can still choose to use out-of-network providers for care, for example if you want to work with a surgeon with special expertise treating your condition. The law does require those providers to provide a good faith cost estimate before they provide the care so you’re aware of the costs you may incur.

I got a surprise bill. What should I do?

Because the law is new, there is a possibility you may receive a surprise medical bill. If you do, your first step should be to call your health insurer to find out if the bill you received from the provider is higher than the in-network cost for the same care. If the bill is higher, let your insurer know that they will need to contact the provider directly to negotiate payment. You may also want to let the provider know that your insurer will be in touch and that you will not pay the bill before the matter is settled.

There’s also a help line (800-985-3059) set up by the Department of Health and Human Services for people who believe they’re received a bill that falls under the new law.


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