What to Do if You Receive a Surprise Medical Bill

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.”

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.​