A surprise medical bill is an unexpected bill from an out-of-network provider or facility. The bill may ask you to pay the difference between the provider’s charge and what your health insurance paid; check the bill for the amount and any date it gives.
What to have in front of you
- The medical bill.
- Your health insurance plan documents, if you have coverage.
- Your good faith estimate, if you received one.
- Any notice and consent form you were asked to sign.
Why you might get a surprise bill
A provider or facility is out of network when it has not negotiated a reimbursement rate with your health insurance company. You may not know a provider or facility is out of network until you receive a bill.
For example, a bill could be for anesthesiology or laboratory tests. Your insurance may not cover the entire out-of-network cost. The difference between the provider’s bill and what your insurance paid is known as balance billing.
When you receive a medical bill, you may have questions about whether you received the treatment listed, whether the amount is correct, whether insurance covers it, or whether some or all of it was already paid.
What the No Surprises Act says
The Consumer Financial Protection Bureau says the No Surprises Act may protect you from certain surprise medical bills. These protections took effect on January 1, 2022.
For people with a group health plan or group or individual health insurance coverage, the Act limits:
- Surprise bills for emergency services from out-of-network providers or facilities, including services received without prior authorization.
- Out-of-network cost-sharing, such as coinsurance or copayments, for emergency services and some non-emergency services.
- Out-of-network charges and balance bills for supplemental care, such as radiology or anesthesiology, from out-of-network providers working at an in-network facility.
The Act aims to bring out-of-pocket costs closer to what they would be for an in-network provider. It generally applies the insurance plan’s copay and cost-sharing percentages.
The Act also requires some providers and facilities to disclose federal and state patient protections against balance billing. It sets out complaint processes for violations of protections against balance billing and out-of-network cost-sharing.
If you have health insurance
The Consumer Financial Protection Bureau says you generally will not be responsible for balance bills or out-of-network cost-sharing for emergency care, certain non-emergency care from out-of-network providers at in-network facilities, or air ambulance services from out-of-network providers.
In those situations, you will generally need to pay normal in-network costs, such as coinsurance, copayments, and amounts paid toward deductibles. The provider and health plan are responsible for negotiating the total payment from the plan to the provider through an independent dispute resolution process.
If your health plan denies all or part of a claim, you can appeal the decision. Your plan documents contain information about the review process and how to request a review.
People covered by Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE may already have protections against surprise medical billing.
If you are uninsured or pay for care without insurance
You should receive a good faith estimate of the cost of your care before you receive it. Your provider should give you an estimate when you schedule the care or call to request one.
If the bill after care is at least $400 above the estimate, you may be able to dispute the charges.
The Consumer Financial Protection Bureau describes a dispute resolution process for a bill that is more than $400 above the good faith estimate, if you received the bill within the last 120 calendar days. A third-party arbitrator reviews the estimate, the final bill, and other information submitted by the provider or facility to determine the final payment amount.
If you are asked to sign a notice and consent form
If you use health insurance, an out-of-network provider or emergency facility may ask you to sign a notice and consent form before certain services. This can happen after you no longer need emergency care. These services are called post-stabilization services.
You may also be asked to sign when scheduling certain non-emergency services with an out-of-network provider at an in-network hospital or ambulatory surgical center.
The form explains your protections from unexpected bills. It gives you the option to give up those protections and pay more for out-of-network care. It also provides an estimate of what the care might cost.
You are not required to sign. The Consumer Financial Protection Bureau says you should not sign if you did not have a choice of provider or facility before scheduling care. If you do not sign, you may have to reschedule with a provider or facility in your health plan’s network.
Questions and complaints
If you have a question about the No Surprises Act or believe the law is not being followed, you can contact the Centers for Medicare & Medicaid Services No Surprises Help Desk at 1-800-985-3059. It is available from 8 am to 8 pm EST, 7 days a week. You can also submit a complaint online.
For a health insurance problem or question, you can contact your state Consumer Assistance Program. These programs help people with health insurance problems and questions about coverage options.
You can also paste the letter into the Clarify Help box on the home page.
Where this comes from
What is a “surprise medical bill” and what should I know about the No Surprises Act?