The No Surprises Act targets medical bill surprises

If you’re like most Americans, “invoice” is probably your least favorite word. “Surprise invoice,” though, is on a whole different level of nightmare.

If you haven’t experienced it yourself, you’ve probably at least heard of it happening to someone you know: The spine-curdling scenario of receiving an unexpected medical bill in the mail for thousands of dollars following your recent ER visit.

It’s not an uncommon situation. In fact, a 2020 Kaiser Family Foundation survey revealed that, on average, 18% of emergency room visits have resulted in at least one surprise bill.

On Jan. 1, 2022, Congress enacted a law that specifically prevents these kinds of surprises from happening.

The No Surprises Act targets unexpected medical bills by providing patients a layer of protection. While it doesn’t eradicate all billing surprises, it’s expected to help reduce concerns, especially for emergency scenarios where patients don’t have time to look for an in-network physician.

How the law protects insured patients

When you need immediate care, you don’t have time to look up which facilities take your insurance. An emergency is an emergency.

Because of this, when you visit an out-of-network provider, you can get hit with a surprise medical bill that is possibly tens of thousands of dollars. According to national polls, the majority of Americans are concerned about not being able to afford a surprise medical bill.

The new law, which went into effect on Jan. 1, specifically addresses this practice.

For people who have health coverage, the new rules:

  • Ban surprise bills when you receive emergency care (including an ER visit, air ambulance, or when you receive non-emergency care at an in-network facility but are unknowingly treated by an out-of-network physician. Yes, this can happen). It also requires co-pays and other cost-sharing for services to be determined by in-network rates.
  •  Prohibits surprise bills from specific out-of-network providers if you go to an in-network hospital for care. As a result, cost-sharing for additional services while you are there will be based on in-network rates.
  • Requires providers and facilities to provide patients straightforward notices explaining applicable billing protections and a contact number, should they have concerns.

How the law protects uninsured patients

If you aren’t insured through an employer or have an individual health care insurance plan, you are considered “self-paying” and must cover all expenses out of pocket.

The No Surprises Act protects you by requiring providers to give a “good faith estimate” of total costs before giving you non-emergency care.

The estimate is required to include projected costs for the main service you’re receiving, as well as any reasonably expected additional services. For example, if you are self-paying and getting surgery, the estimate must include the cost of surgery, diagnostic tests needed, anesthesia, etc.

If you receive a final bill that exceeds the good faith estimate by $400, you have the right to challenge the final charges.

Your state may provide other protections

According to the Commonwealth Fund, many states (more than 30) have introduced surprise medical billing safeguards, but only 17 are considered comprehensive.

The states considered comprehensive offer extended protections to cover non-emergency situations at in-network hospitals. However, they only apply to certain types of insurances and scenarios.

While federal law covers most insurance plans, there are still provisions in state law that differ from federal law. In these specific cases, federal law will defer to states.

Contact your lawyer with questions on your medical bills

Receiving a pricey invoice in the mail is no fun, particularly when it’s an unexpected one. Laws on surprise medical bills can be confusing, especially when they’re changing. Talk to your lawyer to understand your protections and what to do if you receive a surprise medical bill.

Pre-Paid Legal Services, Inc. (“PPLSI”) provides access to legal services offered by a network of provider law firms to PPLSI members through membership based participation. Neither PPLSI nor its officers, employees or sales associates directly or indirectly provide legal services, representation, or advice. The information available in this blog is meant to provide general information and is not intended to provide legal advice, render an opinion, or provide any specific recommendations. The blog post is not a substitute for competent legal counsel from a licensed professional lawyer in the state or province where your legal issues exist and the reader is strongly encouraged to seek legal counsel for your specific legal matter. Information contained in the blog may be provided by authors who could be a third-party paid contributor. All information by authors is accepted in good faith, however, PPLSI makes no representation or warranty of any kind, express or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of such information.