Surprise Billing Protection Form: Know Your Protections Under the No Surprises Act

Under the No Surprises Act, you're protected from surprise medical bills. This law helps prevent unexpected charges when you receive emergency care or visit an out-of-network provider without knowing it.

The No Surprises Act requires healthcare providers to give you a notice of your rights and protections before providing care. This notice must be provided in a clear and easy-to-understand format.

You have the right to choose a healthcare provider or facility that participates in your health plan's network. If you're unsure if a provider is in-network, you can contact your health plan to check.

If you receive a surprise medical bill, you can file a complaint with your state's insurance department.

Surprise billing happens when a health care provider bills a patient for the difference between their charge and the price the insurance company set, after the patient has paid any copays, coinsurance, or deductibles.

This can occur when a patient receives care from an out-of-network provider or facility, such as a hospital. In-network providers agree to accept the insurance payment in full, but out-of-network providers don't have this same agreement with insurers.

Typically, patients don't know the provider or facility is out-of-network until they receive the bill, which can be a shock.

Medical billing is the process of sending and following up on claims with health insurance companies to receive payment for medical services. This process involves submitting detailed claims with the necessary documentation, codes, and information to ensure accurate payment.

Healthcare providers use a standardized system of codes, known as the Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes, to describe the services they provide. These codes are essential for medical billing as they help insurance companies understand the services rendered and process claims correctly.

Medical billing involves working with insurance companies to resolve any issues or discrepancies with claims, which can be time-consuming and frustrating for both providers and patients. In fact, a significant portion of medical billing is spent on follow-up and appeals to resolve these issues.

The medical billing process typically involves submitting claims electronically, which can be done through a variety of platforms and software. This electronic submission helps to streamline the process, reduce errors, and speed up payment.

Balance billing, also known as surprise billing, happens when a healthcare provider bills a patient after the insurance company has paid its share of the bill.

The balance bill is for the difference between the provider's charge and the price the insurance company set, after the patient has paid any copays, coinsurance, or deductibles.

Out-of-network providers don't have an agreement with insurance companies to accept the insurance payment in full, so they may balance bill the patient.

Some health plans, like PPO or POS plans, include some coverage for out-of-network care, but the provider may still balance bill the patient if state or federal protections don't apply.

Typically, patients don't know the provider or facility is out-of-network until they receive the bill.

Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service, which is called balance billing.

This amount is likely more than in-network costs for the same service and might not count toward your plan's deductible or annual out-of-pocket limit.

Out-of-network means providers and facilities that haven't signed a contract with your health plan to provide services.

You may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible, when you see a doctor or other healthcare provider.

You may have additional costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn't in your health plan's network.

Balance billing can happen when you can't control who is involved in your care, 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.

This is called a surprise medical bill, and it can cost thousands of dollars depending on the procedure or service.

The No Surprises Act provides crucial protections against surprise medical bills. The law applies to health insurance plans starting in 2022, covering both self-insured plans and plans from health insurance companies.

You're protected from surprise bills for emergency out-of-network services, including air ambulance services, and non-emergency services at in-network facilities. A facility or provider can't bill you more than your in-network coinsurance, copays, or deductibles for emergency services.

In-network facilities may have out-of-network providers, such as anesthesiologists or radiologists, who can't balance bill you. However, for other services, out-of-network providers can balance bill you unless you give written consent and give up your protections.

Here are some services that are protected from balance billing:

You're never required to give up your protections from balance billing, and you can choose a provider or facility in your plan's network.

The No Surprise Act has some specific rules to help you stay protected.

You're not responsible for surprise medical bills if you get care from an out-of-network provider at an in-network hospital or facility, unless you choose to get care from that specific provider.

You can't be charged more than the in-network cost-sharing for out-of-network care received at an in-network hospital or facility.

If you get care from an out-of-network provider at an in-network facility, you have the right to know in advance how much you'll be charged.

You'll only be charged the in-network cost-sharing for emergency services, even if the provider isn't in-network.

You're protected from surprise medical bills if you get care from an out-of-network provider at an in-network hospital or facility, unless you choose to get care from that specific provider.

You have the right to ask your provider or facility for an estimate of the costs for out-of-network care before you receive it.

You can't be charged more than the in-network cost-sharing for out-of-network emergency services received at an in-network hospital or facility.

The No Surprises Act is a measure that protects consumers with most types of private health insurance coverage against certain surprise medical bills.

It was included in the Consolidated Appropriations Act of 2021, a law that also provided funding for the federal government and COVID-19 pandemic stimulus relief.

The No Surprises Act went into effect on January 1, 2022, after being signed into law on December 27, 2020.

The law covers a wide range of health insurance plans, including fully insured plans, Qualified Health Plans, and self-insured plans governed by the Employee Retirement Income Security Act of 1974.

This means that many people with private health insurance are now protected from surprise medical bills.