Tamia FowlkesMilwaukee Journal Sentinel
Four years ago, Congress passed the No Surprises Act, a law intended to protect people from surprise medical billing. The law went into effect in 2022, introducing new consumer protections and rules.
As of 2024, many details about how the law will be regulated are still being hammered out.
Public Investigator spoke with representatives from the Centers for Medicare and Medicaid Services and the Brookings Institute to break down the ins and outs of the law.
What is balance billing, or surprise billing?
Balance billing is when a medical provider charges you after your health insurance company has paid its share of the bill. It often happens when you get medical care at an out-of-network facility due to an accident or emergency. In that case, it is known as surprise billing.
For example, if a hospital charges $250 for a service, but your coverage limit is $200, your insurance company might charge you the remaining $50.
It is not the same thing as being charged a deductible or co-pay.
Loren Adler, associate director of the Center on Health Policy at the Brookings Institute, said there is no balance billing risk so long as a patient is receiving care at an in-network facility.
Adler also said patients should be notified ahead of time — 48 to 72 hours ahead of an appointment — if they are visiting an in-network facility but the provider they are seeing is out-of-network. In these cases, patients should have the opportunity to consent before receiving out-of-network care.
What does the No Surprises Act do?
The law contains several key protections:
First, the law covers facility-based emergency services. This means that if you go to the ER for an emergency or accident, you do not need to worry about whether your provider is in-network or out-of-network, because you did not have an opportunity to pick your provider.
Second, the No Surprises Act covers patients who receive surprise bills for non-emergency services from out-of-network providers at in-network facilities. An example is if you go to an in-network hospital for a procedure, but your anesthesiologist happens to be out-of-network. In this scenario, if you get a surprise bill, you could dispute it.
Lastly, if you are uninsured, you are entitled to get a good faith estimate of the cost of your treatment beforehand.
More: His insurance card said out-of-network care was covered. Then, he found out it was a typo.
What type of services does the No Surprises Act cover?
The law's protections are heavily determined by where a person receives treatment. Protected facilities include:
- Out-of-network emergency service at a hospital
- Treatment at a hospital outpatient department
- Critical access hospital
- Ambulatory surgical center that has a contractual relationship directly or indirectly with their health plan or insurer
If you receive non-emergency treatment anywhere other than the four locations listed above, the No Surprises Act does not stop providers from balance billing you, Adler said.
In addition, the law's protections only apply to services that are in-network covered benefits.
If a patient chooses to receive out-of-network care at an in-network facility, they are entitled to receive a cost estimate before consenting to waive their protections.
Does the No Surprises Act cover the cost of an ambulance?
Ground transportation in an ambulance is not protected by the No Surprises Act, but air ambulance transportation is.
Am I protected by the No Surprises Act if I'm uninsured?
In general, the main protections in the No Surprises Act only apply to people with private group and individual health insurance coverage, although people who are uninsured do get some.
Specifically, the law grants uninsured patients the right to receive a good faith estimate of the cost of care before the service. If an uninsured or self-pay patient receives a final bill that is substantially greater than the good faith estimate, the patient can initiate a dispute, according to the Centers for Medicare and Medicaid Services.
Does the No Surprises Act require insurers and providers to disclose the cost ahead of time?
No, unless you are uninsured or are choosing to self-pay. In those cases, the No Surprises Act requires that providers and insurers provide "a personalized good faith estimate of expected charges for a health care item or service and expected out-of-pocket costs." This information can be disclosed when scheduling an appointment or upon request.
The federal government has granted hospitals and insurance companies time to adapt to the new rules.
For insured patients, the No Surprises Act does require providers to communicate with insurers to send out an "advanced explanation of benefits" that will explain the estimated cost of a service before the procedure. The explanation should include the following details:
- The estimated cost for the care provider or facility
- The expected amount of coverage from an insurer or health plan
- The patient’s expected cost-sharing
There has been a delay in enforcement of this requirement as the health care industry adjusts.
"This policy is will generally require payers and providers to exchange health data in a way that has never been done before, and technology will need to adapt to ensure that providers and payers can comply," a CMS spokesperson said.
What do I do if I receive a surprise medical bill?
Whether the No Surprises Act applies to your specific situation depends on a number of factors. These factors include: your health insurance coverage, whether the procedure is a covered benefit, whether the provider is in-network or out-of-network, and the setting in which the procedure is completed.
If you receive a surprise medical bill, you can contact your medical provider for an explanation of your appointment's medical coding and contact a patient advocate to help review the bill.
- If you believe you have received a bill in error, you can call the No Surprises Help Desk seven days a week at 800-985-3059.
- You can also file an appeal with your insurance company or file a complaint with the Wisconsin Office of the Commissioner of Insurance using the Surprise Medical Bill Complaint form.
- In addition, you can file a complaint with theCenters for Medicare and Medicaid Services.
It is important to maintain all documents related to an appointment if you intend to file a complaint.
How can I find out the typical cost of a medical service or procedure?
You should be able to find price comparison data online. As of 2024, insurers must publish data that allows patients to compare price and cost sharing information for medical services. The "Transparency in Coverage" rule is meant to help patients evaluate costs among various health care providers before receiving care.
In addition, FAIR Health Consumer is a nonprofit organization that helps consumers understand their healthcare costs and health coverage. Patients can enter their zip code, search treatments and receive cost estimates.
Tamia Fowlkes is a Public Investigator reporter for the Milwaukee Journal Sentinel. Contact her attfowlkes@gannett.com.
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