What Is Surprise Billing and How the No Surprises Act Helps

Surprise billing can be a stressful and confusing experience, especially when you're already dealing with a medical emergency or illness. Surprise billing occurs when you receive unexpected medical bills, often from out-of-network providers.

These bills can be for services like emergency care, lab tests, or even anesthesiology during a surgery. According to the article, in 2020, an estimated 16% of emergency department visits resulted in surprise medical bills.

Surprise billing happens when you receive unexpected medical bills from a provider or facility that's not in your insurance plan's network. This can occur during an emergency or when you schedule a procedure at an in-network facility but are treated by an out-of-network provider.

Surprise billing can also happen when you receive care from a provider or facility that's not contracted with your health insurer, even if they provide services at a hospital or facility that's in your plan's network. In this case, you might receive a bill for the difference between what your insurer agreed to pay and the amount the provider billed for their services.

According to the No Surprises Act, patients are protected from receiving surprise medical bills resulting from out-of-network care for emergency services and for certain scheduled services without prior patient consent.

Here are some reasons why you might receive a surprise bill:

In these situations, you might receive a surprise bill for the difference between what your insurer agreed to pay and the amount the provider billed for their services.

You're protected from surprise billing in several ways. The federal No Surprises Act became effective on January 1, 2022, to help patients understand healthcare costs in advance and minimize surprise medical bills.

If you have employer-sponsored or individual/family health insurance, these protections apply. Surprise bills for most emergency services are prohibited, even if you receive them out-of-network and without approval beforehand.

Surprise bills for supplemental care, like anesthesiology or radiology, by out-of-network providers at an in-network facility are also prohibited. This means you can't be charged more for these services than you would for in-network care.

You're not required to sign a notice explaining that out-of-network care could be more expensive, but healthcare providers and facilities must give you this notice anyway. You're also not required to use your insurance if a service isn't covered or is less expensive if you pay out of pocket.

Here are some key protections you have under the No Surprises Act:

Surprise billing happens when you receive medical care from a provider or facility that isn't part of your health insurer's network. This can occur even if you're treated at a hospital within your network.

Recent laws have started to protect patients from surprise medical bills in emergency situations or when receiving scheduled care from out-of-network providers. In these cases, insurers and providers must go to arbitration to agree on a price for services, and consumers can't be billed for the disputed amount.

If you get a surprise bill, contact the provider or facility and tell them you believe you've been wrongly billed. You can also file a complaint with the relevant office and they will investigate on your behalf.

Here are some reasons why surprise billing occurs:

If you get a surprise bill, contact the provider or facility and tell them you believe you've been wrongly billed. This can often resolve the issue quickly.

You can also file a complaint with your state's insurance office and they will investigate on your behalf. This can provide an added layer of protection and help ensure you're not unfairly charged.

Recent state and federal laws have been put in place to prevent surprise medical bills in certain situations, such as emergency care or scheduled procedures at in-network facilities.

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.

Healthcare providers and facilities have specific responsibilities when it comes to surprise billing. They must tell you which provider networks they participate in on their website or if you ask.

You have the right to expect transparency from your healthcare providers. They must refund any amount you overpay within 30 business days.

In most cases, providers and hospitals cannot ask you to limit or give up your rights. This means you have certain protections against surprise billing.

Here are some key responsibilities of healthcare providers and facilities:

Medical providers and facilities must be transparent about their network participation. They should clearly list the provider networks they participate in on their website or inform you if you ask.

You have the right to know who to expect to be in network, and it's their responsibility to provide this information.

If you overpay for medical services, providers and facilities must refund the amount within 30 business days.

They cannot ask you to limit or give up your rights, which include the right to be informed about their network participation and the right to a refund if you overpay.

Here are the specific actions providers and facilities must take:

Balance billing is a common issue that can arise when you receive medical care from a provider or facility that isn't part of your health plan's network. This can happen unexpectedly, even if you've scheduled a visit at an in-network facility.

You may be surprised to receive a bill for the difference between what your plan agreed to pay 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 annual out-of-pocket limit.

To avoid balance billing, it's essential to know which provider networks your medical providers and facilities participate in. They must tell you on their website or if you ask. You can also ask your insurance plan to provide you with a list of in-network providers.

Here are some key facts about balance billing:

If you get a surprise bill, contact the provider or facility and tell them you believe you've been wrongly billed. You can also file a complaint with the relevant office and they will investigate on your behalf.

In-network services offer a range of benefits, including protection from balance billing. Certain services at an in-network hospital or ambulatory surgical center are covered, and out-of-network providers can't balance bill you for those services.

Emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services are all covered under in-network services. These providers can't balance bill you and may not ask you to give up your protections.

You have the right to choose a provider or facility in your plan's network. You're never required to give up your protections from balance billing.