How No Surprises Act May Help With Unexpected Medical Bills

The No Surprises Act is a federal law enacted to protect patients from unexpected medical bills incurred on or after January 1, 2022. It aims to address the issue of surprise medical billing, which can occur when patients receive unexpected charges for their medical care. The Act applies to out-of-network emergency services, out-of-network air ambulance services, and certain out-of-network care received at in-network facilities.

Help for Seniors

The Act is important for all patients, but especially for seniors. Seniors are especially vulnerable to surprise medical billing because they often need more health care than other populations. They are more likely to be seen by out-of-network providers. The Act protects them from unexpected charges and provides a much-needed safeguard for their medical expenses.

Under the Act, patients are not responsible for surprise medical bills beyond their in-network cost-sharing amount. This means that patients will only be responsible for paying the same amount they would have paid if an in-network provider provided the care. The Act also prohibits balance billing, which is when providers bill patients for the difference between their charges and the amount paid by the patient’s insurance.

This can be relevant in a variety of settings seniors encounter, including emergency room visits, second opinions, surgical procedures, and even skilled nursing care where independent contractors provide services. Under the Act, providers must accept the Medicare-approved amount as payment in full. This prevents patients from being surprised with large balances and protects them from unexpected financial hardship.

Exceptions to the Act

There are some providers and services that are exempt from the Act’s billing protections (although your state may have a similar law that does not exempt them). These include:

• Ground ambulance services, which can charge you out-of-network rates
• Vision-only and dental-only insurances, which are not subject to balance billing protections
• Indemnity plans such as hospital indemnity insurance, which are exempt from the Act

If You Are Uninsured

For uninsured or self-paying patients, the No Surprises Act provides rules for a good faith estimate of how much a medical service will cost. You may request an estimate if you schedule a medical service at least three business days out or simply ask for one. If your final bill is $400 or more than the estimate, you may be able to dispute it. Having a good faith estimate allows patients to make informed decisions about their care.

Independent Dispute Resolution

To resolve payment disputes between providers and insurers, the Act establishes an independent dispute resolution (IDR) process. This process allows providers and insurers to submit their proposed payment amounts to an independent arbiter who makes the final decision. The IDR process aims to protect patients from being caught in payment disputes and ensures a fair resolution for all parties involved.

(Editor’s Note: The IDR process is on temporary pause as of August 2023.)

Pricing Transparency

In addition to protecting patients from surprise medical bills, the Act also includes provisions to increase health care pricing transparency. Health insurers must provide patients with clear and detailed information about their health care coverage. This includes a description of providers’ network status and estimated cost-sharing amounts. This increased transparency aims to empower patients to make informed health care decisions and avoid unexpected charges.

The No Surprises Act is a significant step toward addressing surprise medical billing and protecting patients from financial harm. By implementing clear rules and procedures, patients are not caught off guard by unexpected charges and have access to fair dispute resolution. With the Act in place, patients can have more confidence in seeking medical care, knowing they will not face unexpected financial burdens.