No Surprises Act
The No Surprises Act legally protects you against surprise medical bills after Jan. 1, 2022, whether you have insurance or not. Health care providers and insurance companies are now required to provide accurate, good faith estimates for medical bills. If the two parties cannot come to an agreement, then it must go through an independent dispute resolution (IDR) process.
You may have experienced the shock of having a procedure done in an in-network facility only to receive a bill of service from a physician who’s out-of-network.
For example, an investigative health reporter tweeted that she delivered her baby at an in-network hospital but received a $22,000 bill for an epidural because the anesthesiologist was out-of-network. It seems implausible and can be a complicated, drawn-out process to try to resolve. Yet according to the Kaiser Family Foundation, this happens to 1 in 5 emergency claims and 1 in 6 in-network hospitalizations among privately insured patients.
The No Surprises Act was created to help combat these types of occurrences from happening and to save you from receiving surprises medical bills.
What Is the No Surprises Act?
According to the Centers for Medicare & Medicaid Services (CMS), the No Surprises Act was created to protect people from receiving unwarranted medical bills from out-of-network providers at in-network facilities, as well as services from out-of-network air ambulance service providers. The law went into effect on January 1, 2022.
- Air ambulance services
- Diagnostic services (i.e., laboratory services)
The No Surprises Act does not affect people with Medicare and Medicaid. Part of the basics of Medicare is that beneficiaries have rights related to their coverage, which include protection against surprise medical billing.
Other Protections Included
The No Surprises Act removes privately insured patients from the negotiation process between health care providers and insurance companies. This means the two must come to an agreement without getting the patient involved. If they cannot, then it must undergo the independent dispute resolution (IDR) process.
- Requires health care providers and insurance companies to bill reasonably.
- Implements protection against insurance companies discriminating against health care providers.
- Ensures continuity of services for beneficiaries when there is a change in their plan’s provider network.
- Requires insurance companies to stay true to online price comparison tools, so patients can compare expected out-of-pocket costs for items and services across multiple providers.
- Requires insurance companies to ensure their provider directories are accurate.
The law also protects the uninsured by allowing them to dispute a medical bill that is substantially greater than the original quote or estimate they received from the provider.
How Is the No Surprises Act Enforced?
The No Surprises Act is primarily enforced by state. If your state does not provide adequate enforcement, then CMS will take over enforcement.
According to the National Law Review, CMS and individual states will conduct random investigations to ensure that consumers are not overpaying, without relying solely on complaints or other information indicating that there has been a violation. CMS may also conduct random or targeted investigations of health care providers or facilities.
Penalties of up to $10,000 will be imposed on providers or facilities that are found to have violated the No Surprises Act.
What Do I Do If I Received a Surprise Medical Bill?
If you received a surprise medical bill for services provided in 2022, then you have 120 days from the date on your bill to file a dispute if your final charges are at least $400 above your good faith estimate.
6 Cited Research Articles
- Centers for Medicare & Medicaid Services (2022, April 12). Medical Bill Disagreements If You’re Uninsured. Retried from https://www.cms.gov/nosurprises/consumers/medical-bill-disagreements-if-you-are-uninsured
- Pollitz, K. (2021, December 10). No Surprises Act Implementation: What to Expect in 2022. Retrieved from https://www.kff.org/health-reform/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022
- Centers for Medicare & Medicaid Services. (2022, January 3). No Surprises: Understand Your Rights Against Surprise Medical Bills. Retrieved from https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills
- The National Law Review. (2021, October 19). Surprise! It’s the No Surprise Act. Retrieved from https://www.natlawreview.com/article/surprise-it-s-no-surprises-act
- Kaiser Family Foundation. (2021, February 4). Surprise Medical Bills: New Protections for Consumers Take Effect in 2022. Retrieved from https://www.kff.org/private-insurance/fact-sheet/surprise-medical-bills-new-protections-for-consumers-take-effect-in-2022/
- American Hospital Association. (2021, January 14). Detailed Summary of No Surprises Act. Retrieved from https://www.aha.org/system/files/media/file/2021/01/detailed-summary-of-no-surprises-act-advisory-1-14-21.pdf