More Americans worry about unexpected medical bills than any other expense, according to polls by the Kaiser Family Foundation, yet 18% of emergency visits and 16% of in-network hospital stays had at least one out-of-network charge, a 2020 Peterson-KFF Health System Tracker study found.
The No Surprises Act, which bans most surprise medical bills as of Jan. 1, could ease those worries.
“This law puts an end to the practice of charging patients exorbitant bills for unexpected, out-of-network care,” says U.S. Sen. Patty Murray, D-Wash., who chairs the Senate Health, Education, Labor and Pensions Committee.
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Here’s a look at what the No Surprises Act aims to do and what it might mean for your finances.
Surprise medical bills
A surprise medical bill is one you weren’t expecting from an out-of-network provider, typically when you didn’t choose the doctor or didn’t know that physician wasn’t in your network.
“You don’t control where the ambulance takes you for an emergency treatment,” says Patricia Kelmar, health care campaigns director for the United States Public Interest Research Group, a federation of consumer advocacy organizations. “You don’t control who’s giving you anesthesia or doing your lab work once you’re in a hospital — in your in-network hospital.”
Insurers often require higher copayments, coinsurance or deductibles for out-of-network care. The provider also can bill you for what’s left after your insurer pays its portion of the bill, a practice called balance billing.
What the law does
The No Surprises Act bans balance billing for emergency services and some non-emergency services.
First, your insurance has to cover emergency services as in-network with no prior authorization. Balance billing isn’t allowed for emergency care even at out-of-network hospitals or emergency departments.
If you go to an in-network hospital or ambulatory surgical center for non-emergency care, balance billing isn’t allowed for any of these ancillary services:
- Anesthesiology, pathology, radiology or neonatology.
- Care from assistant surgeons, hospitalists or intensivists.
- Diagnostics like radiology or laboratory services.
- Any other item or service from an out-of-network provider if an in-network provider wasn’t available.
You can’t waive or lose your protection against balance billing for emergency services or ancillary services at in-network facilities. You only ever need to pay your in-network copay, coinsurance or deductible.
Consent for out-of-network billing
You might want care from a specific provider like an expert in a specialized surgery even if that specialists is out-of-network. An out-of-network provider at an in-network facility can send you a balance bill only if all of these are true:
- The provider isn’t on the ancillary services list above.
- The doctor gives you a plain-language explanation of your rights.
- You give written consent to give up your protections against balance billing.
If you don’t give consent, they can’t bill you as out-of-network — but can refuse to treat you.
“I really encourage patients to think very, very carefully before they waive their rights and sign that form,” Kelmar says. “They have every right to ask for an in-network provider. The hospital has to provide them one … If they want to stay in-network, they should not sign the form.”
Disputes over what you owe
If you’re paying for services yourself, you have the right to a good-faith cost estimate. If a provider bills you $400 or more above that estimate, you can challenge the bill.
If you’re using insurance, your insurer can tell you what’s covered and estimate your out-of-pocket costs. If your insurer denies a claim because it says certain services aren’t covered, you can dispute that decision.
Kelmar and U.S. PIRG worked with the federal government to set up what she calls a “one-stop shop to go to with any questions and complaints.” You can call (800) 985-3059 or go online to CMS.gov for disputes or any other issues related to the No Surprises Act.
Arbitration between providers, insurers
The No Surprises Act “provides insurance companies and health care providers a fair process to resolve [out-of-network] bills without additional cost to patients,” Murray says.
You don’t need to be involved in negotiations or disputes between providers and your insurer. If they disagree over a payment, they need to work it out themselves or use a new arbitration process.
While patients aren’t directly involved, “We really do care about how well arbitration works,” Kelmar says. “It was very important to us that there was a reasonable payment made to the provider that wouldn’t increase costs in the long run for our health plans — that we would then see passed on to us in our premiums in the future.”
What’s not covered
The law doesn’t ban all surprise and out-of-network bills. Here are two important exceptions:
- Ambulances: The new law covers air ambulances but not regular ground ambulances.
- Facilities: The law applies to care provided in hospitals, emergency departments and ambulatory surgical centers. Other facilities, such as clinics and urgent-care centers, aren’t included.
These protections don’t apply to those who are covered by Medicare, Medicaid, TRICARE, Veterans Affairs Health Care or Indian Health Services because they’re already protected against surprise medical bills.
