Everybody loves surprises, but not in the form of penalties or unexpected financial dues. In healthcare, one of the most unwelcome surprises is receiving a large medical bill for services the patient never agreed to and could not reasonably avoid.
Take the example of this case in Texas, a man was rushed to an in-network hospital for an emergency breathing problem, and he believed his care was fully covered by insurance. Months later, he received a surprise bill of about $2,000 from out-of-network doctors who treated him during that emergency visit. Although his main hospital bill was covered, the separate physician charges were not initially paid.
The case highlights how patients can receive unexpected medical bills despite using in-network facilities.
What Is the No Surprises Act?
The No Surprises Act is a federal law that took effect on January 1, 2022, protecting patients from unexpected medical bills when receiving emergency care or treatment from out-of-network providers at in-network facilities. This legislation applies to emergency services, non-emergency services from out-of-network providers at in-network facilities, and air ambulance services.
How Does the No Surprises Act Protect Patients from Unexpected Bills?
The No Surprises Act protects patients by limiting out-of-pocket costs to in-network rates for covered emergency room services and certain non-emergency services. Patients pay only their in-network cost-sharing amount, such as copayments, coinsurance, or deductibles.
The law prevents healthcare providers and facilities from balance billing patients for the difference between the provider’s charge and the insurance payment.
Key Protection Areas
The Act protects in 3 specific healthcare situations:
Emergency services at any facility
Emergency care at hospital emergency departments, freestanding emergency centers, or urgent care facilities cannot result in surprise bills.
Non-emergency services at in-network facilities
Services from out-of-network providers at in-network hospitals or ambulatory surgical centers are protected.
Air ambulance services
Emergency air ambulance transportation from out-of-network providers is covered under the Act.
What Medical Services Are Covered Under the No Surprises Act?
Medical services covered under the No Surprises Act include the following:
- Emergency care
- Anesthesiology
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeon services
- Hospitalist services
- Diagnostic services
According to the Centers for Medicare & Medicaid Services (CMS), these protections apply to both insured and uninsured patients receiving care at participating facilities.
Emergency VS. Non-Emergency Services Protection
Emergency Services Protection
Emergency services receive the strongest protection under the Act. Patients cannot be balance billed for emergency care regardless of whether the facility or provider is in-network. The law defines emergency services as services provided after a medical screening examination to stabilize the patient’s condition.
Non-Emergency Services Protection
Non-emergency services at in-network facilities require advance notice if out-of-network providers will be involved. Providers must obtain written consent at least 72 hours before scheduled services. This consent requirement does not apply to ancillary services like anesthesiology, pathology, radiology, and laboratory services.
What Are Your Rights Under the No Surprises Act?
Your rights under the No Surprises Act include receiving a good-faith estimate of costs, limiting out-of-pocket expenses to in-network amounts, and filing complaints against providers who violate the law. Patients have the right to:
- Receive advance notice of out-of-network care for non-emergency services
- Consent to waive protections only for scheduled non-emergency services
- Access an independent dispute resolution process for billing disputes
- Report violations to federal authorities without retaliation
Good Faith Estimate Requirements
Healthcare providers must provide uninsured or self-pay patients with a good-faith estimate of expected charges. This estimate must be provided at least 1 business day before scheduled services or within 3 business days of scheduling. The estimate must include expected charges from the provider, facility, and any other providers involved in care.
How Can You Avoid Surprise Medical Bills?
You can avoid surprise medical bills by verifying provider network status before scheduled services.
“According to research, approximately 18% of emergency visits and 16% of in-network hospital stays resulted in surprise bills before the Act’s implementation”.
Steps to Prevent Surprise Bills
Follow these 5 steps to minimize surprise billing risks:
- Verify all providers are in-network before scheduled procedures
- Request written confirmation of network participation from facilities
- Ask about ancillary service providers, including anesthesiologists and radiologists
- Obtain good-faith estimates if paying without insurance
- Review the explanation of benefits statements carefully after receiving care
What Should You Do If You Receive a Surprise Bill?
Contact your health insurance company immediately if you receive a surprise bill for protected services. Review the bill to determine if it violates the No Surprises Act protections. Document all communications with providers and insurers regarding the disputed charges.
Dispute Resolution Process
The independent dispute resolution (IDR) process allows patients to challenge surprise bills. Initiate the process within 120 days of receiving the initial bill. Federal agencies provide free assistance through the No Surprises Help Desk at 1-800-985-3059. The IDR process typically resolves disputes within 30 days of initiation.
How Does the No Surprises Act Affect Uninsured Patients?
The No Surprises Act affects uninsured patients by requiring providers to offer good-faith estimates of costs and limiting total charges to estimates. Uninsured patients paying cash rates can dispute bills exceeding the good faith estimate by $400 or more.
Patient-Provider Dispute Resolution
Uninsured patients can initiate dispute resolution for bills substantially exceeding estimates. The patient-provider dispute resolution process requires providers to justify charges above the estimated amount. Resolution typically occurs within 30 business days through a selected dispute resolution entity.
What Are the Penalties for No Surprises Act Violations?
Penalties for No Surprises Act violations include civil monetary penalties up to $10,000 per violation.
- The Department of Health and Human Services
- The Department of Labor
- The Department of the Treasury
These bodies enforce compliance. Providers who knowingly violate balance medical billing prohibitions face additional penalties and potential exclusion from federal healthcare programs.
Conclusion
If you still have queries about NSA, you can consult with Connecticut Medical Billing, because we have:
- Expert knowledge of No Surprises Act requirements and regulations
- Accurate coding and billing that prevents compliance violations
- Transparent patient communication regarding estimated costs
- Efficient dispute resolution support for providers and patients
- Regular compliance audits to identify and correct billing errors
Protect your patients and your practice from surprise billing violations. Contact Philadelphia Medical Billing today to ensure your billing practices comply with the No Surprises Act and federal regulations. Our medical billing experts provide comprehensive solutions that safeguard patient relationships while maximizing appropriate reimbursement. Schedule a consultation to learn how we can streamline your billing operations and eliminate surprise billing risks.
FAQs
When would the No Surprise Act not apply?
The No Surprises Act (NSA) doesn’t apply to government programs like Medicare, Medicaid, VA, or TRICARE, nor does it cover short-term insurance or situations where you knowingly waive protections for non-emergency, out-of-network care after getting a good faith estimate. It also excludes certain “excepted benefits” like standalone dental/vision and retiree-only plans. Essentially, if your coverage is through a federal program or it’s a specific limited-benefit plan, the NSA’s core surprise billing protections generally don’t apply.
What happens if I cannot pay my hospital bills?
If you fail to make payments, you will receive letters from a creditor’s attorney warning you of the action the creditor plans to take
What happens if you don’t pay medical bills under $500?
If you don’t pay a medical bill under $500, it won’t hurt your credit report as the major bureaus stopped reporting such debts in 2023. However, the provider might still send it to collections, and you could face future care refusal or even legal action, though lawsuits for small amounts are rare. While the credit impact is gone, the debt remains, and providers can sell it, so it’s best to contact the provider about payment plans or financial aid.
How Does Connecticut Medical Billing Ensure No Surprises Act Compliance?
Connecticut Medical Billing ensures No Surprises Act compliance by implementing comprehensive billing practices that protect patients from unexpected charges. Our team stays current with federal regulations, verifies network participation, and provides accurate good-faith estimates to all patients.