Passed in 2020, the No Surprises Act aims to shield patients from surprise medical bills. This law became effective in 2022 and established new regulations to protect consumers.
While some aspects are still under development (as of 2024), understanding the key points of the No Surprises Act can empower you to make informed decisions about your healthcare.
What is balance billing, also known as surprise billing?
Balance billing occurs when a healthcare provider bills you for the difference between their charges and the amount your insurance company pays. This often happens during emergency situations where you receive care at an out-of-network facility.
Think of it like this: A hospital charges $250 for a service, but your insurance covers only $200. You might be billed the remaining $50 by the hospital.
Important note: Balance billing is distinct from your deductible or co-pay.
Transparency is key. Patients should be informed well in advance (48-72 hours before an appointment) if they’re visiting an in-network facility but seeing an out-of-network provider. This allows you to make a choice about proceeding with the care.
No Surprises Act: Protection from Surprise Medical Bills
The No Surprises Act protects patients from unexpected medical bills in several situations:
- Emergency care: Even if you end up at an out-of-network emergency room, you can’t be billed extra for the facility or attending physician because you couldn’t choose your provider in an emergency.
- Surprise bills at in-network facilities: If you have an in-network procedure but receive a surprise bill from an out-of-network provider (like anesthesiologist), you can dispute the charges under the No Surprises Act.
- Good faith estimates for the uninsured: If you don’t have health insurance, you have the right to get a cost estimate upfront for your medical treatment.
Where Does the No Surprises Act Apply?
The Act protects patients in specific treatment settings:
-
- Emergency rooms at any hospital (even out-of-network)
- Hospital outpatient departments
- Critical access hospitals
- Ambulatory surgical centers contracted with your health plan
If you receive non-emergency care outside these settings, the provider can still send you a balance bill for the difference between their charges and your insurance payment.
Important Note: The Act only applies to services covered by your in-network plan. If you choose an out-of-network provider at an in-network facility, you can still be billed extra, but you have the right to a cost estimate before agreeing to waive your No Surprises Act protections.
What if I Don’t Have Insurance?
The No Surprises Act’s main protections are for those with private health insurance. However, there are some benefits for uninsured patients.
-
- Good Faith Estimates: The law requires providers to give you a good faith estimate of the ambulance cost upfront, before the service is rendered.
- Disputing Bills: If the final bill is much higher than the estimate, you can initiate a dispute process.
Disclosure of Costs Upfront
Generally, insurers and providers aren’t required to disclose costs in advance for insured patients.
Exceptions:
-
- Uninsured or Self-Pay: In these cases, you’re entitled to a “good faith estimate” of both the provider charges and your out-of-pocket costs.
- Advanced Explanation of Benefits (EOB): For insured patients, providers are supposed to work with insurers to send an EOB outlining estimated costs, insurance coverage, and your portion before the service. However, enforcement of this is currently delayed.
Challenges with Implementation
The No Surprises Act requires significant data sharing between insurers and providers, which is a new process for the healthcare industry. This could lead to delays in receiving cost estimates.
Got a surprise medical bill? Here’s what you can do:
-
- Check if the No Surprises Act applies: This law protects you from certain out-of-network charges. It depends on your insurance, the service, and the location.
- Review the bill: Call your doctor to understand the charges and coding. Consider getting help from a patient advocate.
- Dispute the bill: If you think it’s wrong, call the No Surprises Help Desk (800-985-3059).
- Appeal or complain: You can appeal with your insurer, file a complaint with the state insurance office, or with the Centers for Medicare and Medicaid Services. Keep all your appointment documents for this.
Want to estimate medical costs beforehand?
-
- Use online tools: By 2024, insurers must provide price comparison information. This helps you shop around for services.
- Check FAIR Health Consumer: This non-profit gives cost estimates based on your zip code and chosen treatment.
How Medical Billing Companies Can Fight Surprise Billing:
Here are some things medical billing companies can do to mitigate the effects of surprise billing:
-
- Work with providers to ensure they are in-network: Companies can encourage providers to participate in their networks and offer them competitive rates.
- Invest in transparency tools: Medical billing companies can develop tools that help patients understand their potential out-of-pocket costs before they receive care.
- Stay up-to-date on regulations: Companies should stay informed about the latest laws and regulations related to surprise billing and make sure their practices are compliant.
By taking these steps, medical billing companies can help to reduce the number of surprise bills and improve the patient experience.