Sometimes your health insurance may not cover most of the out-of-network costs, and it can leave you with an unexpected balance bill. A balance bill is a difference between your actual bill and the amount paid by your health insurance. These balance bills have been surprising many Americans with unexpected out-of-pocket medical expenses.
The surprise bills contain costs of out-of-network services that they did not choose. According to the federal government, almost 40 million patients visit the hospital for emergency care, and 1 out every 5 cases will involve an out-of-network claim.
What is balance billing or surprise billing?
When you visit a doctor or other healthcare provider, you may be required to pay out-of-pocket expenses such as a copayment, coinsurance, or a deductible. If you see a provider or visit a healthcare facility, not in your health plan’s network, you may incur additional costs or be required to pay the entire bill.
Out-of-network providers and facilities have not signed a contract with your health plan. Out-of-network providers may be able to bill you for the difference between what your plan agreed to pay and the total cost of a service. This is known as “balance billing.” This amount is likely higher than the in-network cost for the same service and may not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you have no control over who is involved in your care, such as when you have an emergency or schedule a visit at an in-network facility but are treated by an out-of-network provider.
What is the ‘No Surprises Act’?
A new federal law called the ‘No Surprises Act’ (NSA) has been in effect from January 1, 2022. If you have individual or group health insurance, it can protect you from surprise bills. It does this in the following ways:
You can’t be balanced billed for emergency services provided by an out-of-network provider without your knowledge.
The Act bans out-of-network cost-sharing, such as coinsurance or copayments. This applies to all emergency and some non-emergency services.
Out-of-network non-emergency services also can’t exceed the patient’s in-network cost. It does not matter if you were notified or consented to the treatment in this case. This includes anesthesia, pathology, radiography, neonatology, and laboratory services.
How can this Act benefit you?
As of January 1, 2022, when you get medical care from out-of-network providers at certain in-network facilities, you will not have to pay for it out of your pocket. Instead, you’ll usually only have to pay for your standard in-network costs. The health care provider and your health plan will figure out how much your plan will pay to the provider through an independent process.
If your health plan denies all or part of a claim for service, you can try to contest that. Your plan documents can tell you about the review process and how you can appeal for a review of your plan’s decision to deny your claim.
The no surprise billing Act also ensures that an out-of-network provider cannot balance bill you for any emergency medical service. Your plan’s in-network cost-sharing amount is the maximum an out-of-network provider may charge you.
If you don’t have insurance or self-pay for your own care, the new rules ensure that you can get a good faith estimate of how much your care will cost before you get it.
If your final charges are $400 or more over your good faith estimate, you can file a dispute claim within 120 days of the date on your bill.
What is a ‘good faith estimate’?
All health care providers are required to give uninsured patients, or those who don’t have insurance or aren’t using it, an estimate of how much they will be billed for scheduled items or services or on request for other non-emergency items or services. A good faith estimate can be asked for by anyone, with or without insurance.
If you don’t have health insurance, you have the right to a ‘good faith estimate‘ of how much you will be charged for scheduled or non-emergency items or services. The estimate should include the costs of expected items and services, like medical tests and hospital fees, that will be given during the visit.
If you have insurance, you can also ask for a ‘good faith estimate‘ of how much you will be charged for items and services that aren’t emergencies.
You have the right to get the estimate in writing at least one business day before the medical service or item you are scheduled to get. Before you plan an item or service, you can also ask your health care provider or any other provider you choose for a good faith estimate.
Whether or not you have insurance, you can dispute a bill if the estimate you get for the everyday items and services is higher than the amount you are charged for.
Here are a few plans that are excluded from the ‘No Surprises Act’
- Health reimbursement plans
- Plans that are exclusively comprised of excepted benefits
- Plans with a limited time frame
- Plans for retirees only
- Plans with less than two current employees participating
The ‘No Surprises Act’ regulates types of ‘Medical services’
- Emergency services
- Professional services from outside the network are given at in-network facilities. (Unless the provider has a signed permission slip from the patient for the out-of-network service.)
- Emergency and non-emergency air ambulance
- Under the NSA, emergency services include care given in hospital emergency rooms and care offered in emergency rooms separate from hospitals.
- The NSA defines non-emergency care as care given in hospitals, hospital outpatient departments, critical-access hospitals, and ambulatory surgical centers.
- For this new law and its accompanying regulations, care provided in a physician’s office is neither emergency nor non-emergency.
Where can you go for more information or register a complaint?
If a debt collector contacts you about an unexpected medical bill or surprise medical expenses, you can file a complaint with the ‘No Surprises Help Desk.’ To do so, call 1-800-985-3059. For questions or more information about your right to a good faith estimate, you can also go to www.cms.gov/nosurprises.