Understanding Unexpected Medical Bills and Your Rights

You're probably aware that medical bills can be overwhelming, but did you know that 66% of Americans have trouble paying medical bills? It's a common problem.

Many unexpected medical bills are caused by surprise medical billing, which occurs when a patient receives care from an out-of-network provider without their consent. This can happen even if the patient has insurance.

You have the right to know the costs of your care and to request an itemized bill. Under the No Surprises Act, healthcare providers must give you a good faith estimate of the expected charges for your care before it's provided.

Surprise medical billing can be financially devastating, with some patients receiving bills for tens of thousands of dollars.

Surprise billing happens when a patient receives an unexpected balance bill after receiving care from an out-of-network provider or at an out-of-network facility. This can happen for both emergency and non-emergency care.

Typically, in emergency care, patients don't know the provider or facility is out-of-network until they receive the bill. This can be a shock, especially if the patient has already paid their copays, coinsurance, or deductibles.

Balance billing can happen when a patient receives covered, emergency healthcare services from an out-of-network provider or an out-of-network facility. This is because out-of-network providers may be permitted to bill patients for the difference between what their insurance plan agreed to pay and the full amount charged for a service.

Some health plans, such as Preferred Provider Organization (PPO) or Point of Service (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.

Here are some examples of situations where surprise billing can occur:

It's essential to understand that surprise billing is a real concern, and patients should be aware of their rights and protections under the No Surprises Act, which applies to health insurance plans starting in 2022.

You're protected from surprise bills for emergency services, including air ambulance services, but not ground ambulance services.

The No Surprises Act applies to health insurance plans starting in 2022, covering both employer-offered self-insured plans and plans from health insurance companies.

A facility or provider may not bill you more than your in-network coinsurance, copays, or deductibles for emergency services, even if they're out-of-network.

You're also protected from surprise bills for non-emergency services at an in-network facility.

Out-of-network providers at in-network facilities can't bill you more than your in-network copays, coinsurance, or deductibles for covered services.

You can't be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility for certain services, such as emergency medicine or radiology.

If you choose to go out-of-network, you'll be expected to pay the balance bill as well as your out-of-network coinsurance, deductibles, and copays.

Here are the key protections under the No Surprises Act:

If you're treated for an emergency at a hospital, you're protected from surprise bills for out-of-network providers. This means you'll only have to pay your in-network cost-sharing for the treatment.

In New York, consumers are protected from surprise bills for emergency services in hospitals, including inpatient care following emergency room treatment. This means you won't receive a surprise bill for services provided by an out-of-network doctor or provider.

You only have to pay your in-network cost-sharing (copayment, coinsurance, and deductible) for bills from out-of-network providers for emergency services. This includes bills from doctors, the hospital, and other providers who treat you.

Here's a breakdown of what you might have to pay:

If you receive a bill from an out-of-network provider for emergency services, let your health plan know right away. You may also file a complaint with DFS.

You have the right to be protected from surprise medical bills, which can be a huge financial burden. The No Surprises Act applies to health insurance plans starting in 2022, and it's a game-changer.

If you receive emergency services from an out-of-network provider, you can't be billed more than your in-network coinsurance, copays, or deductibles. This applies to services like air ambulance, emergency room visits, and even some non-emergency services at an in-network facility.

Here are some key protections to know:

Remember, you're not required to sign any notice or get care out-of-network, and you can't be asked to waive your protections. If you do choose to go out-of-network, you'll be expected to pay the balance bill as well as your out-of-network coinsurance, deductibles, and copays.

If you're uninsured, you're still protected by the No Surprises Act.

Health care providers must give you a good faith estimate of their expected charges before you receive care. This estimate must include a description of the service, a list of other services that are reasonably expected to be provided, the diagnosis and expected service codes, and the expected charges.

You have the right to ask for a good faith estimate at any time, and providers must give it to you within 3 business days.

Here's a breakdown of when you can ask for a good faith estimate and when providers must give it to you:

This means that if you're uninsured, you can ask for a good faith estimate before you receive care, and providers must give it to you within the specified timeframe.

The good news is that you don't have to pay for independent dispute resolution (IDR) when you're disputing a bill with your health care provider. However, the cost of IDR is typically borne by the party that loses the dispute.

If you're a patient disputing a bill with your provider, you won't have to pay for IDR unless the IDR determines that your provider's fee is reasonable. If that's the case, you'll be responsible for paying the cost of IDR unless it would pose a hardship to you. A hardship is defined as a household income below 250% of the Federal Poverty Level.

In some cases, the provider pays the cost of IDR, while in other cases, the health plan pays. Here's a breakdown of the cost of IDR in different scenarios:

It's worth noting that there may be a minimal fee to the provider or health plan submitting the dispute if the IDR determines that the dispute is ineligible or incomplete.