It’s an all-too-common scenari: Your loved one needed a trip to the emergency room and an extended hospital stay. You’re now thrilled as they’re recovering at home—until a huge, unexpected bill arrives in the mail.
Apparently, your loved one received care from an out-of-network provider while in the hospital, even though you had no choice in providers or even an awareness of whether a provider or facility was out-of-network. Now, that thrill turns into a feeling of helplessness, as you have no idea how your loved one will pay this bill—and you know the threat of another unexpected bill will make your loved one that much more resistant to a hospital trip the next time an emergency arises.
Luckily, a new law called the No Surprises Act was signed in December 2020 (and went into effect on Jan. 1, 2022) to protect patients from unexpected medical bills. And while this bill is a huge improvement, it doesn’t offer a 100% guarantee against surprise medical bills. Here’s what you should know:
What are surprise medical bills?
If a patient had health insurance or received care from an out-of-network provider or facility, his or her health plan may not have covered the entire out-of-network cost—even if they didn’t know they were receiving out-of-network service. Additionally, the out-of-network provider or facility could bill the patient for the difference between the billed charge and the amount the health plan paid, a practice called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill. (People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.)
The No Surprises Act: What to know
In short, the Centers for Medicare and Medicaid Services explains that the No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
Additionally, it establishes a dispute resolution process for payment disputes between plans and providers, and also provides new dispute resolution opportunities for uninsured and self-pay individuals if they receive a medical bill that’s substantially greater than the estimate they got from the provider.
What does this mean for my loved one?
This doesn’t mean a trip to the emergency room or hospital will be free. Instead, this law will eliminate the risk that an out-of-network doctor or hospital will send an extra bill. The patient will still be responsible for things like a deductible or co-payment, but should expect no more bills outside of a normal payment.
The law also requires that health care providers and facilities provide an easy-to-understand notice explaining the billing protections, who to contact if you have concerns a facility or provider has violated the protections, and that patient consent is required to waive billing protections. Patients can dispute a medical bill if final charges are at least $400 more than the good faith estimate.
Patients should be aware that it’s still important to choose an in-network facility and main doctor for routine, scheduled procedures. If your loved one chooses an out-of-network doctor or facility for a routine procedure, that doctor needs to provide notification at least three days before the procedure to offer a “good faith estimate” of the cost of the service. Patients can dispute a medical bill if final charges are at least $400 more than the good faith estimate as long as they do not sign a form agreeing to pay extra. Experts recommend that patients should think very carefully before agreeing to sign a form because it waives all their protections.
What’s not covered
Patients should understand the new law does not prevent ambulance companies from billing you directly for their services if they travel on roads, but does offer protections against surprise bills from air ambulances.
And while this new law provides a great service to patients, it doesn’t eliminate all the issues. If your loved one has an insurance plan with a high deductible or has coinsurance that requires them to pay a percentage of their medical charges, they could still get a big bill in the mail after a procedure. Patients should continue to specifically confirm that their doctors are “in network” for routine procedures, noting there could be a significant cost difference between “in network” and whether they “accept your insurance.”Understanding the ins and outs of insurance coverage and advocating for your loved one’s rights could save time, money and hassle in an emergency.