Surprise Billing

Understanding the No Surprises Act

Highlights

In the past, people have received surprise medical bills because a provider and/or facility were out of network and were billed for the difference between what was billed and what insurance would have allowed if the provider or facility had been in network. This is called balance billing. And now under the No Surprises Act (NSA), that is not allowed and can be disputed.

Medicare and Medicaid programs have had similar rules in place for many years. If you have a dispute and are insured by Medicare and/or Medicaid, contact them directly. They will walk you through the appropriate dispute process.

What is the No Surprises Act — and who does it cover?

The Consolidated Appropriations Act of 2021 contains requirements to protect people with private insurance from surprise medical bills. These rules were collectively known as the No Surprises Act.

If you’re insured through an employer, the health insurance marketplace, or have an individual health plan, you should be protected by the No Surprises Act, which took effect January 1, 2022. However, governmental insurance programs like Medicare and Medicaid aren’t covered by the NSA since these programs are already protected against surprise bills and they can be contacted directly when there is a dispute. 

What are your rights under the No Surprises Act?

Patients covered by the No Surprises Act (NSA) have a right to access emergency care from out-of-network providers without being charged extra. In short, you should not get a big bill that you didn’t expect for that care. Nor should you get a surprise bill for non-emergency care if you go to a facility covered by your insurance.

Your other rights include:

  • No prior authorization required: You don’t have to make sure a hospital or doctor who practices at that facility is covered by your insurance before getting emergency care to avoid a surprise bill.
  • You should get a notice about these billing protections at the hospital, surgery center, or outpatient clinic including information on who to contact (see below) if you have concerns.
  • A debt collector can’t force you to pay a bill that exceeds what’s allowed under the NSA. You can contact the Consumer Financial Protection Bureau (CFPB) if you have an issue with medical debt collection or credit reporting. To address unfair medical debt and related negative items on your credit report, call the CFPB at 1-855-411-2372 (CFPB) or file a complaint online.


However, The NSA doesn’t prevent all surprises related to out-of-pocket medical costs. Sometimes what seems like a surprise bill has more to do with the structure of your health plan than the bill itself. For example, you may have a high-deductible plan but not realize how much of the deductible you still have to pay.

Review your explanation of benefits to better understand what your insurance covers after you receive care. Then compare that to your bill.

What is a good faith estimate in healthcare?

A “good faith estimate” (GFE) is a written statement designed to help project your cost of care. In the case of a planned surgery, for example, a good faith estimate would include:

  • The surgeon’s fee
  • Anesthesiology fee
  • Facility charges

The NSA says uninsured and self-pay patients (those who pay out of their own pocket) should get a good faith estimate if they want one. If you request a GFE because you’re uninsured or are paying cash, you’re supposed to have this billing estimate in hand 3 hours before same-day care and at least 3 days before an elective procedure.

If your final charges are $400 or more over the good faith estimate, you can dispute it through what’s called the patient-provider dispute resolution process. Disputes must be filed with 120 days of the bill date.

How to Get Help

If you received a surprise bill or have questions about the No Surprises Act, you can contact our office. If you still have questions, or you have a dispute that could not be resolved by speaking to us, you can contact the No Surprises Help Desk for free at 1-800-985-3059. You can also file a complaint to the Centers for Medicare & Medicaid Services (click “submit a complaint”) if you feel a provider didn’t adhere to the NSA.

The help desk can be reached from 6 AM to 6 PM MST, 7 days a week.

The Bottom Line

If you receive a surprise bill, please contact us as soon as possible. If you still have a dispute or have questions you can call the No Surprises Help Desk. In cases where medical debt or collections problems result from a surprise bill, the Consumer Financial Protection Bureau has resources that may help you protect your credit rating.

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