There’s one less thing privately insured Americans need to worry about if they experience a medical emergency: getting an unexpected bill from a health care provider who was involved in their treatment but was out of their insurance plan’s network — a practice that used to happen in about 1 in 5 emergency room visits, according to the Kaiser Family Foundation (KFF).
These so-called surprise medical bills — which often arose when patients had little or no say in where they received care or who gave it — became illegal starting Jan. 1, 2022, under a law called the No Surprises Act. The law is expected to save millions of Americans with individual or employer-sponsored health plans hundreds, if not thousands, of dollars in unforeseen medical expenses in certain situations, while helping to drive down insurance premiums overall.
What are the new protections against surprise billing?
The No Surprises Act:
- Bans surprise billing for emergency services, including air ambulance services.
- Bans out-of-network cost sharing for all emergency and some non-emergency services.
- Forbids out-of-network providers to bill patients for ancillary care (like an anesthesiologist or assistant surgeon) at in-network facilities.
Source: Centers for Medicare & Medicaid Services
Emergency services, even if they’re provided out of network, now must be covered at a patient’s in-network rate. And people who receive routine care at in-network facilities no longer have to fear extra bills from out-of-network providers who were involved in their care without their knowledge. For example, an out-of-network surgical assistant who helped your in-network surgeon cannot bill you more for services — the same goes for the anesthesiologist who put you to sleep and the radiologist who read your X-rays. Patients are liable only for their expected in-network cost sharing amount in these situations; insurers and providers are left to settle the rest.
“This new law will make sure that you won't get a bill that looks any different than the one you would have gotten if you were using an in-network provider,” says Jack Hoadley, research professor emeritus at Georgetown University’s McCourt School of Public Policy. (Surprise billing was already prohibited under Medicare and Medicaid.)
Air ambulances, which can cost tens of thousands of dollars, are also forbidden from charging privately insured people out-of-network fees under the new law. “If you're in the unfortunate situation where you have to take a helicopter or plane for medical reasons, even if that's an out-of-network provider, you shouldn't get a bill,” says Erin Duffy, a research scientist at the Schaefer Center for Health Policy and Economics at the University of Southern California. Ground ambulances, however, are exempt from the rule.
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What to do if you get a surprise bill
Even with the new law in place, experts say it’s still important for insured individuals to pay attention when reviewing their medical bills. After all, with roughly 10 million surprise bills sent out annually before the law went into effect, a few cases could “fall through the cracks,” Hoadley says. “I think eventually it should be a situation where the consumer just doesn't have to think about this, but at the start, that's probably not going to be the case for everybody,” he adds.
First, it’s important to know the difference between a surprise bill as it pertains to the new law and a bill that is surprisingly more than you were expecting. Plans with high deductibles or coinsurance can still yield high bills, so read up on what your insurance covers and know that if you have a high deductible, you will have to pay it before cost sharing kicks in.
“You might be out for $2,000 on a medical procedure that's completely in network, that's a completely appropriate bill, you just haven't met your deductible,” Hoadley says. “So that's a surprise, but it's not what we're calling a surprise bill in the case of this law.”
Other protections for patients
The No Surprises Act also:
- Removes patients from payment disputes. Providers and insurers will work out payment issues through a defined resolution process.
- Mandates that patients be informed ahead of time if care is out of network. An out-of-network provider or facility must notify the insured patient at least three days before their appointment. The patient must consent to any out-of-network care.
- Requires that insured individuals receive an advanced explanation of benefits. Scheduling a surgery? Insured patients should receive an explanation of benefits in advance from their health insurer with the network status of the provider or facility, the provider’s good-faith estimate of the charges, and an estimate of expected cost sharing.
- Requires that uninsured individuals receive a good-faith estimate. Uninsured individuals will also have a better idea of how much health services cost ahead of time. The new law requires that providers and facilities provide a good-faith estimate that includes an itemized list of items and services and their expected charges.
Second, know what to look for: Duffy says surprise bills typically come from a physician’s group or a lab, for example, and not necessarily from the hospital or health facility where you received care. So if you notice a bill separate from your hospital bill, “that's when you would want to look at things more carefully,” she says. Compare that bill to the explanation of benefits sent by your insurer and see if there are any discrepancies. A bill that suggests you owe a balance beyond your expected in-network copay or deductible is a red flag.
If you think you were billed incorrectly for your care, start by calling your insurer. You can also call the provider for an explanation — it could just be the result of a billing mistake. If you still don’t get answers to your questions, the Department of Health and Human Services has a new complaints system for surprise bills; the number for the No Surprises Helpdesk is 800-985-3059.
And remember: The new protections kicked in Jan. 1, so it is possible to receive a legal surprise bill after that date for treatment that was administered before the law took effect.
A few exceptions
Patients who want to receive non-emergency care from a health care provider who is outside their health plan’s network — say, they want to schedule a knee replacement with a specific orthopedic surgeon — will still be able to do so under the new law, by way of a waiver. This waiver must be signed in advance of the procedure or appointment; the patient should also receive a “good-faith estimate” of how much their care will cost. “But you can never be asked to sign that type of waiver for an ancillary provider [like an anesthesiologist or surgical assistant] under the No Surprises Act,” Duffy says.
Another thing to note about the new law: It doesn’t cover ground ambulance transportation, a common source of surprise medical bills, although several states do have laws that prohibit out-of-network fees from ambulances. So it’s still possible to get a high bill for your ride to the hospital. You could also be on the hook for unexpected costs if you’re transferred from one hospital or health facility to another by way of an out-of-network ambulance.
If you are in a non-emergency situation where you or a family member can confirm the network status of an ambulance company ahead of time — for example, if a patient is being transferred from a hospital to a nursing home — it’s a good idea to do so, Duffy says. “There are still areas where we need to be vigilant,” she adds.
Finally, pay attention to where you are receiving treatment. These new protections apply only to care administered at hospitals, hospital outpatient departments and ambulatory surgery centers. They don’t apply to non-emergency services provided in other facilities such as birthing centers, clinics, hospice, addiction treatment facilities, nursing homes and many urgent care centers, KFF explains. Patients will want to check ahead of time to make sure their health care provider is considered in-network before seeking care at these facilities.
Hoadley also advises patients to inquire about the in-network status of imaging centers if they are referred to one by a primary care physician, to avoid unexpected charges.
Rachel Nania writes about health care and health policy for AARP. Previously she was a reporter and editor for WTOP Radio in Washington, D.C. A recipient of a Gracie Award and a regional Edward R. Murrow Award, she also participated in a dementia fellowship with the National Press Foundation.