For many Americans, paying medical bills is an insurmountable burden. Many who struggle to pay their medical debt, find themselves diverting funds for basic necessities including food, housing and utilities. They may delay or skip necessary health care services altogether. A major contributor to such financial stress is unexpected medical bills from out of network providers. For example a patient may require surgery for their condition. The patient’s health insurance assures them that the hospital and surgeon are covered. Post surgery, the patient receives a surprise bill for anesthesia which was not covered. This is what is known as a balanced bill. Balance billing is the difference between the charges the provider billed and the amount payed by a person’s health plan. As of January 1, 2022, the No Surprises Act provides federal protection from some surprise medical bills by banning balance billing for emergency services and some nonemergency services.
The new law protects all commercially insured patients. Public insurance programs such as Medicare and Medicaid already have such protections. Out of network providers are barred from billing patients more than in network cost amounts for the following services:
- All out of network emergency facility and professional services
- Post-stabilization care at out of network facilities until a patient can be safely transferred to a different facility
- Anesthesiology, pathology, radiology or neonatology
- Care from assistant surgeons, hospitalists or intensivists
- Diagnostics such as radiology or laboratory services
- Any other item or service from an out of network provider if an in network provider wasn’t available
The No Surprises Act doesn’t ban all surprise and out-of-network bills. Here are two important exceptions:
- Ambulances: The act covers air ambulances, but not regular ground ambulances.
- Facilities: The act applies to care provided in hospitals, emergency departments and ambulatory surgical centers. Other facilities like clinics and urgent care centers aren’t included but might be added later.
An out-of-network provider at an in-network facility can only send a balance bill if a patient receives a plain-language explanation of their rights and gives written consent. If consent is not given, they can’t bill a patient as out-of-network. The provider though, can refuse treatment. Patients have a right to ask for an in-network provider, and the hospital must provide one.
If a patient is paying for services themselves, they have the right to a good-faith cost estimate from the provider. If a provider bill is $400 or more above that estimate, the bill can be challenged. If a patient is using insurance, the insurer can explain what is covered and estimate the out-of-pocket costs. If the insurer denies a claim because it says certain services aren’t covered, that decision can be disputed. For disputes or any other issues related to the No Surprises Act, call 800-985-3059 or visit CMS.gov.
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