The No Surprises Act: Patient Protection From Surprise Medical Bills, a Dispute Resolution Process

Patients and their families with individual or employer health insurance now have some protection from receiving surprise medical bills. The No Surprises Act has been crafted to protect consumers from unexpected medical bills for most emergency or non-emergency care. This includes out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Uninsured, those who self-pay, as well as disputes between providers and healthplans will also have a path for dispute resolution. The Act took effect on January 1, 2022. 

What the No surprises act Says

Patients should receive “good faith estimates” prior to a service/procedure

Beginning January 1, 2022, health care providers, facilities, and health plans will have to provide upfront costs to consumers. This includes potential out-of-network costs. The uninsured or those not using their insurance (self-pay), should receive an estimate over the phone or in-person. The estimate will be of the expected charges (a “good faith estimate”) prior to receiving a medical service. This should be followed-up with a written estimate including details of all the services, billing code, and associated charges.

This estimate should include the cost of:

• The primary service that the person receives, such as surgery
• Additional services associated with the primary service, such as:
  • Laboratory testing
  • Anesthesia

However, items or services that are separately scheduled, such as a pre-surgery consultation, may not be included in this estimate. Beginning in 2023, your provider’s facility will also be required to provide cost information. This would include co-providers and co-facilities used for the scheduled service. 

Here is an example of what a good faith estimate looks like: https://www.cms.gov/files/document/good-faith-estimate-example.pdf. 

No balance bills

If you have health insurance, the following will be banned:

• Surprise bills for emergency services, even if they are from an out-of-network provider
• Higher cost sharing for out-of-network services (all emergency and some non-emergency services)
  • This means patient cost sharing has to be the same, whether the facility is in-network or out-of-network
• Out-of-network charges and balance bills for supplemental care (anesthesia, imaging), even from out-of-network providers working at an in-network facility
  • Sometimes, even if a care facility is within your health plan’s network, a specialist working there may not be. This can result in “balance bills” to patients to cover the costs the health plan may not cover.

Dispute Resolution

Uninsured or self-pay:

For uninsured and self-pay patients, a dispute resolution process is available to resolve surprise bills from health care providers after having received a good faith estimate. The following criteria need to be met by uninsured or self-pay patients:

• You received a good faith estimate from the health facility or provider
• The bill was received within the last 120 calendar days 
• The difference between the good faith estimate and the bill is at least $400

For those using a health plan:

If your insurance company denies paying for all or a part of your medical service, and if this violates the No Surprises Act, you can ask for an external review. Consider the following examples:

• If your health plan covers emergency services and you received emergency care at an out-of-network ER, coverage should be the same as an in-network ER. If this payment is denied or only partially paid by the plan, you can appeal.
• Items and services from an out-of-network provider at an in-network hospital should be covered at an in-network rate. If you are charged at an out-of-network rate, you can appeal it, unless you gave consent to be charged the out-of-network rate.

What’s the Bottomline for Patients?

Beginning January 1, 2022, insured patients are no longer responsible for paying balance bills or out-of-network cost-sharing. Patients will only be responsible for the in-network copay or coinsurance amount. You should not receive a separate bill directly from a doctor or health care facility that is out-of-network. The health plan and the health facility/doctors have to resolve the payment dispute via an independent dispute resolution process.

How Do I Know if my Health Bill Qualifies as a Surprise Medical Bill?

It is up to the health plans and doctors/health care facilities to inform the patient whether the charge in the bill is protected under the No Surprise Act. Both must also inform patients about their surprise medical bill protections, through a direct notice and via a public website. 

If patients do not receive this information, it is up to them to distinguish a surprise medical bill or balance bill. 

Here’s what some commonly used terms mean:

• In-network and out-of-network costs. The difference in cost of a service depending on whether a doctor or hospital are in your health plan’s network. 

In-network facilities and doctors have a contract with your health plan for a discounted rate. The plan will then cover 80% of the discounted rate and the patient covers 20%.

Out-of-network facilities and doctors charge their full rate, which is usually not recognized by the health plan. The health plan pays the facility based on the in-network rate, and the remaining amount is billed to the patient. 

• Surprise bill. An unexpected bill to the patient from a medical facility or a doctor.
• Balance bill. When patients seek care from facilities outside their plan’s network, the facility bills the patient for the “balance” not covered.  Out of network doctors can also do this.
• Good faith estimate. A document uninsured and self-paying patients should receive prior to their service. It includes an estimate on the amount that they will be billed for scheduled or non-emergency services and items. 

More reading

Health Care Providers Unhappy With CMS’ Interim Final Rule on Surprise Billing

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