20 Jan Surprised by a Medical Bill? Here’s What to Do.
If you’ve ever been surprised by a medical bill, you’re not alone. An estimated 10 million patients a year receive the shock of unexpectedly high medical bills for emergency or out-of-network care from providers they did not choose.
Many with chronic illnesses or those who have suffered a medical emergency know this reality all too well. Even for non-emergency surgeries, consumers have been surprised to learn that their surgeon used an out-of-network anesthesiologist or consulted with another doctor during the surgery. And now, those medical service providers expect the patient to pay their full, undiscounted rate.
As this problem has continued to grow for patients, a handful of states have passed laws to protect patients from surprise medical billing practices after visiting the ER or when getting care from out-of-network providers.
In 2020, Congress, with bipartisan support, passed the federal No Surprises Act (NSA) to protect consumers from surprise medical bills. Now, finally, the NSA is (as of 1/1/22) in effect.
How does the No Surprises Act protect consumers from surprise medical bills?
The NSA protects consumers by 1) mandating private health insurance cover out-of-network surprise bills and 2) preventing health care providers from billing patients more than in-network prices for those surprise medical bills.
What does this mean? Out-of-network providers will have to submit the bill to a patient’s insurance. The insurance company will reply with what they determine to be the median in-network rate. Once the out-of-network provider receives payment from the insurance company, they can only bill the patient for their regular in-network co-insurance amount.
What does the NSA cover?
The No Surprises Act applies to both emergency medical services and non-emergency medical services. Emergency care includes care provided when a patient goes to the emergency room as well as active labor. While the NSA covers air ambulances, it does not apply to ground ambulances.
As for non-emergency services, the bill addresses labs, imaging, pre-operative and post-operative services, as well as charges for out-of-network telemedicine.
What should consumers do if they get a surprise medical bill?
It is important for consumers to know their rights. If the insurance company or health care provider does not properly identify a medical bill as a surprise, the patient has to be the one to complain about the bill to the insurance company or health care provider.
Hopefully, insurance companies and health care providers will work with patients to fix these errors. But, if not, patients can file a payment dispute with the U.S. Department of Health and Human Services by calling the No Surprises Help Desk at 1-800-985-3059. They can also file a payment dispute online.
If the federal government finds that a provider has charged a patient more than an appropriate in-network co-insurance amount, the provider could be fined up to $10,000.
What else do patients need to be aware of?
An out-of-network provider is allowed to ask patients to waive their NSA rights for non-emergency procedures. However, if a patient refuses to consent, the provider is allowed to refuse care.
But, waiving rights, is not allowed for services such as anesthesiology, pathology, diagnostic services, or in situations where an out-of-network provider is the only option.
If a provider asks a patient to waive their No Surprises Act rights, the provider has to hand the patient a form that explains the patient’s rights, a description of the services, and an estimate of the costs the patient will have to pay. This must take place at least 72 hours before the service (or no later than 3 hours before if service is scheduled for the same day).
Does the NSA protect me from surprise medical bills if I’m uninsured?
If you are uninsured or choosing not to use insurance, health care providers must give you a good faith estimate of the cost of your care. If the actual cost exceeds the estimate by more than $400, then you have 120 days to file a dispute with HHS.
What about Medicare and Medicaid patients?
The NSA does not apply to Medicare and Medicaid patients – they already enjoy similar rights.
About Triage Cancer
For more information about navigating your health insurance coverage, see our module on CancerFinances.org. If you need help managing medical bills, learn how you can get free services for one year through CoPatient. Learn more and sign up.
Triage Cancer is a national, nonprofit providing free education to people diagnosed with cancer, advocates, caregivers, and health care professionals on cancer-related legal and practical issues. Through events, materials, and resources, Triage Cancer is dedicated to helping people move beyond diagnosis.