No Surprises Act

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 who received out-of-network services.

The No Surprises Act was created to help combat these types of occurrences from happening and to save you from receiving surprise medical bills.

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.

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.

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.

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.

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.

If you are uninsured and 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.