Surprise out-of-network medical bill? How the No Surprises Act works

What a surprise bill is

You go to an in-network hospital. Weeks later, a bill arrives from an anesthesiologist or radiologist you never chose and who isn't in your plan's network. They bill you the difference between their full charge and what your plan allowed. That practice is called balance billing. HealthCare.gov gives a simple example: if the provider charges $100 and the allowed amount is $70, the provider may bill you for the remaining $30.

The federal No Surprises Act, in effect since January 1, 2022, limits this in specific situations. Knowing whether your bill is one of them is the first step.

Who the protections cover

CMS says the protections apply to people with health coverage through an employer (including Federal Employees Health Benefits plans), through the federal or a state Marketplace, or through other individual coverage.

People whose only coverage is Medicare, Medicaid, TRICARE, VA care or Indian Health Service care are outside these particular rules; CMS notes those programs already have some billing protections of their own. If you are uninsured or choose not to use insurance, a different protection applies: the right to a good faith estimate.

Which bills are protected

According to CMS, the protections cover three situations.

1. Emergency care. Emergency services at a hospital emergency room, an independent freestanding emergency department, or hospital care after you are stabilized. This applies even if the facility or doctor is out of network and even without prior authorization.

2. Non-emergency care at in-network facilities. Care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, even if an individual provider who treats you there is out of network.

3. Air ambulance. Services from out-of-network air ambulance providers.

In these cases, CMS says you shouldn't be charged more than your plan's in-network cost sharing: your usual copay, coinsurance and deductible.

What isn't protected

CMS lists situations the federal protections do not cover:

• Ground ambulance. Not covered by the federal rules, though CMS notes state law may differ.

• Some plan types. Vision-only and dental-only plans, short-term limited duration plans, health care sharing ministries and fixed indemnity plans, such as hospital indemnity insurance.

• Certain settings. A doctor's office that isn't a hospital outpatient department, or an out-of-network facility you chose.

• Care where you validly gave up the protections. See notice and consent, below.

Notice and consent: the one form to read carefully

For some planned, non-emergency care, an out-of-network provider may ask you to sign a notice and consent form. Signing means you agree to out-of-network care and give up these protections for that care; CMS says you will likely pay more.

CMS sets rules for this form. It must include a cost estimate and information about your protections, and it must be given separately from other paperwork and in advance. Signing is your choice, but if you don't sign, the provider may decline to treat you and you may need to reschedule with an in-network provider.

Some providers can never ask you to sign it. CMS lists emergency room care and services from assistant surgeons, hospitalists and intensivists, as well as emergency medicine, anesthesiology, pathology, radiology, neonatology and diagnostic services. If you got a balance bill from one of these after signing a form, that is worth raising.

Is this bill protected? A quick test

Ask yourself:

1. Do I have private coverage through work, the Marketplace or an individual plan?

2. Was this emergency care, care connected to a visit at an in-network hospital or surgery center, or an air ambulance?

3. Is the provider out of network, and is the bill more than my in-network cost sharing?

4. Did I sign a notice and consent form, and was the provider one of those allowed to ask?

If the answers point to a protected situation, the bill may not reflect what you owe.

A sample, decoded

Sample statement · Northgate Anesthesia Associates (synthetic)

Date of service 08/21 · Northgate Surgery Center · Anesthesia services · Charges $2,600.00 · Insurance paid $1,040.00 · Balance due $1,560.00

Sample EOB · Northgate Health Plan (synthetic)

Out-of-network provider · Allowed $1,300.00 · Plan paid $1,040.00 · Your coinsurance (in-network rate) $260.00

The surgery center is in network. Anesthesiology is on the list of services that can't ask you to waive the protections. The plan processed your share at in-network rates: $260. The provider's $1,560 balance appears to include the difference between its charge and the allowed amount, which these rules are designed to prevent in this situation.

What to do with a bill you think is protected

1. Check your EOB

Compare the bill with the explanation of benefits. Look at what the plan allowed and what it lists as your share. The plan's notice about surprise billing protections must also appear on EOBs for items and services covered by the law, according to CMS's sample notice guidance.

2. Call the provider's billing office

Tell them the care was at an in-network facility (or was emergency care) and that you believe the No Surprises Act limits your bill to in-network cost sharing. Ask them to review and correct the bill. Note the date and name.

3. Call your plan if the EOB is wrong

If the plan processed the claim at out-of-network rates when it shouldn't have, CMS says to use your plan's appeal process. Note that CMS says an unmet deductible is not a violation of the law; you still owe your normal in-network share.

4. Submit a complaint

CMS says you can submit a complaint to the No Surprises Help Desk if you got an out-of-network bill for emergency care or an in-network facility visit, if you already paid more than in-network rates for such a visit, or if a provider didn't follow the notice and consent rules. The Help Desk number is 1-800-985-3059, and CMS also takes complaints online.

5. Check your state's rules

Some states have their own surprise billing rules, and CMS notes that state law may differ for ground ambulance bills. Your state insurance department can tell you what applies.

If your provider leaves your network mid-treatment

CMS describes a separate protection: if you are a continuing care patient, for example in treatment for a serious illness, pregnant or scheduled for non-elective surgery, you may be able to keep in-network rates for up to 90 days after your provider leaves the network. Ask your plan whether you qualify.

Have your surprise bill checked

EasyToDecode, launching soon, will read the bill and your EOB, quote the lines that show where the care happened and who billed for it, and flag signs that federal surprise billing rules may be relevant. It will also draft a letter you can edit and send to the provider. See how it works or join the waitlist.