Surgery is scary enough. But for the past few years, stories about getting huge surprise bills after going under the knife have made the prospect even scarier.
Congress finally took action and as of Jan. 1, the No Surprises Act protects you from many forms of surprise billing. Here’s how the new law works and what to do if you still get a surprise medical bill.
The No Surprises Act
The No Surprises Act applies to people covered under group and individual health insurance plans — mostly people who get their coverage from an employer or the federal and state health insurance marketplaces. It creates three major protections:
It bans surprise bills if you receive emergency services, even if you get them from an out-of-network provider and don’t receive prior authorization from your insurance company.
If you receive emergency services (and some non-emergency services) you won’t have to pay the out-of-network price for copays or coinsurance. The law requires you to be charged no more than the average in-network out-of-pocket price for your area.
If you are visiting an in-network facility (say you’re giving birth or having surgery), you won’t be charged the out-of-network price if the anesthesiologist or radiologist or anyone else providing additional services is not in your health insurance network.
Health care providers are required to provide easy-to-understand explanations of these protections and let you know who to contact if you think they’ve violated the law. The Centers for Medicare and Medicaid have set up a hotline at 1-800-985-3059 and an online complaint form for any disputes.
Ideally, you as a patient shouldn’t even be aware all this is happening. Even if you get a bill from an out-of-network provider, they should submit it to your insurance company first so they know to charge you the in-network price.
“The insurer is supposed to tell the provider how much your in-network cost share would be and then and only then can they bill you,” says Caitlin Donovan, a spokeswoman for the Patient Advocate Foundation.
Less than a month after taking effect, it’s hard to know how successful the No Surprises Act has been thus far, but similar laws at the state level have been effective, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.
“By and large, those have been very successful at preventing patients from receiving out-of-network bills,” Adler says.
What to do if you get a surprise bill
The No Surprises Act is still relatively new and it doesn’t cover everything. There still may be instances where health care providers send bills they shouldn’t under the law, says Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy.
“There will probably also be cases where insurers don’t appropriately apply cost-sharing calculations as they’re supposed to under the law,” Fiedler says.
Providers can be penalized up to $10,000 for violating the No Surprises Act, but your first call if you get a bill you’re confused about should probably go to your insurance company. Just because you get a big medical bill doesn’t mean it’s covered by this law. For example, your health insurance might come with a high deductible, in which case you have to pay out of your own pocket until you meet that deductible. That might be surprising (especially given how confusing health insurance plans are), but it’s not a “surprise bill” under this law.
“Most patients’ first line of defense when they get a surprise bill is to call their insurance company and that should get things resolved,” Adler says.
If you still suspect that the bill you’ve got is breaking the law, you can call the CMS hotline as well as the consumer protection agency in your state. And take a close look at the bill itself before paying it. Medical bills often come with errors that you can dispute. Plus, you can often negotiate their costs down.
→ Read our guide to dealing with medical bills
What’s not covered in the No Surprises Act
While the No Surprises Act covers air ambulances, it does not cover ground transportation, most likely owing to the hodge-podge of local laws covering ambulance service. Ambulance service is often out-of-network, and even when you call an ambulance, the 911 dispatcher, not the patient, picks the service. (This is why people sometimes opt to take a ride-hailing service instead.)
The law requires the government to study ground ambulance costs, but in the meantime, it’s still a good idea to set aside money in your emergency fund and, if you have a high deductible health plan, your health savings account, in the event of a medical emergency.
Image: Charles Gullung / Getty Images
