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After an unexpected medical event or emergency procedure, many patients face a frustrating and costly burden: an unexpected medical bill. Navigating the financial side of healthcare can be complex for patients, insurance companies, and providers, especially when determining who is responsible for covering the costs.

Healthcare spending in the U.S. continued to rise in 2023, increasing by 7.5% to reach $4.9 trillion, according to data from the Centers for Medicare & Medicaid Services (CMS). This total accounts for expenses related to public health initiatives and government administration, as well as the more conventional costs of health insurance and medical services. Although 92% of Americans had health insurance coverage in 2023, based on U.S. Census Bureau reports, medical care in the U.S. remains expensive—particularly when services are received from out-of-network providers.

Health insurance policies outline what services are covered and the extent of that coverage. Typically, in-network services are more affordable than out-of-network care. While patients usually have the option to choose in-network providers, certain circumstances, such as emergencies, may prevent them from doing so. When emergency care is received at an out-of-network facility, patients may be left with costly medical bills they did not anticipate. The Consumer Financial Protection Bureau estimates that over 100 million Americans collectively owe more than $220 billion in medical debt.

To address this issue, the federal government enacted the No Surprises Act (NSA), which took effect on January 1, 2022. Below is an overview of this law and the consumer protections it provides.

Understanding Surprise Medical Bills

During an emergency, patients are often unable to select their healthcare provider or verify the costs associated with their care. They may receive treatment at an in-network hospital but still be billed for services provided by out-of-network specialists, such as anesthesiologists or radiologists.

When this occurs, the healthcare provider bills the insurance company, which determines the portion of the cost it will cover. The remaining balance is then charged to the patient—a practice known as “balance billing,” which results in a surprise medical bill. This type of billing refers to unexpected charges for care that patients had no prior opportunity to review or consent to.

There are several common scenarios in which surprise medical bills occur, including:

• Emergency treatment by an out-of-network provider
  In urgent medical situations, patients may not have a choice in where or how they receive treatment. If an out-of-network ambulance or air ambulance is used, or if the patient is treated at an out-of-network facility without prior authorization, they may receive a surprise bill.
• Out-of-network services within in-network facilities
  Even if a patient visits an in-network hospital, they may receive care from out-of-network specialists, such as radiologists or anesthesiologists, without prior knowledge. This can result in unexpected charges.
• Out-of-network cost-sharing for emergency services
  Patients may also be billed for additional costs such as co-insurance or co-payments for out-of-network emergency services, which they did not approve beforehand.

How the No Surprises Act Protects Patients

Since its implementation on January 1, 2022, the No Surprises Act has provided safeguards against surprise medical billing, primarily focusing on out-of-network charges related to emergency care. However, it also offers some protections for non-emergency medical services.

The law applies to both individual and group health insurance plans. Additionally, it includes measures to assist uninsured individuals or those who choose to pay out of pocket for their medical expenses. To address payment disputes related to surprise bills, the law also establishes an independent resolution process.

Key Protections Under the No Surprises Act Include:

• Capping out-of-network emergency service charges
  Patients receiving emergency care from out-of-network providers will now pay costs similar to those for in-network care. The law ensures that insurers determine appropriate payments based on recognized market pricing, often referencing in-network rates.
• Limiting charges from out-of-network providers at in-network facilities
  If an in-network hospital provides post-stabilization services through out-of-network practitioners without obtaining prior approval, the NSA restricts how much patients can be billed. This cost is determined using qualifying payment amounts, typically based on standard market rates.
• Preventing excessive out-of-network cost-sharing
  Many insurance policies require cost-sharing through co-pays and co-insurance. The NSA prohibits excessive cost-sharing for emergency and certain non-emergency services, ensuring that patients are charged fairly.
• Transparent billing information
  Patients must be informed of their protections against surprise billing before being asked to waive them. This ensures they are not unknowingly agreeing to balance billing.
• Good faith estimates for uninsured patients
  Without an insurance plan to estimate costs, it can be difficult for patients to anticipate their medical expenses. The NSA requires that uninsured or self-paying patients receive a good faith estimate before undergoing medical treatment.

These provisions aim to reduce the cost disparities between in-network and out-of-network services and eliminate surprise billing in certain situations.

Resolving Disputes

While the No Surprises Act offers significant consumer protections, navigating the IDR process can still be challenging for healthcare providers. No Surprise Bill, in alignment with the No Surprise Act, specializes in assisting providers with Independent Dispute Resolution process, helping them streamline claims disputes, reduce IDR fees, and secure favorable financial outcomes. Their expertise ensures that healthcare practices receive fair and timely payments while maximizing revenue retention. The team consists of experienced professionals with deep knowledge of healthcare regulations, insurance policies, and dispute resolution strategies. Their commitment to efficiency and compliance allows healthcare providers to focus on patient care while minimizing financial losses from surprise billing disputes.

Who Is Covered Under the No Surprises Act?

Healthcare coverage varies widely, and the No Surprises Act is designed to help protect different types of patients from unexpected medical expenses. However, these protections depend on the type of insurance coverage a person has. The NSA complements, rather than replaces, existing state laws, meaning some individuals may already be protected under state regulations.

The law applies to:

• Individuals with employer-sponsored group health plans
• Those with Health Insurance Marketplace plans
• Individuals with private, directly purchased insurance plans

Additionally, the NSA ensures that:

• Uninsured and self-paying patients receive a cost estimate upfront before medical services are provided.

Certain groups already have existing protections against surprise billing and are not covered under the NSA, including:

• Medicare beneficiaries
• Medicaid recipients
• TRICARE participants
• Individuals receiving care through the Indian Health Service
• Veterans receiving care through the VA

What to Do If You Receive a Surprise Bill

Under the No Surprises Act, patients should no longer receive unexpected medical bills for emergency care, out-of-network air ambulance services, or certain non-emergency procedures at in-network facilities. If a surprise bill is received, the law provides a process for resolving disputes.

For insured patients, if a balance bill is issued for covered services, they can challenge the charge through their health plan. The insurance provider and healthcare facility must resolve the payment dispute using an independent arbitration process outlined by the NSA. Patients should only be responsible for in-network cost-sharing amounts, such as co-insurance, co-payments, and deductibles.

For uninsured or self-paying individuals, any bill exceeding the initial good faith estimate by $400 or more qualifies as a surprise medical charge. A dispute can be filed within 120 days of receiving the bill, triggering an arbitration process to determine a fair payment amount.

If a healthcare provider or insurer fails to comply with the law, patients can submit a complaint online through the official CMS website or contact the No Surprises Help Desk.