Do not pay medical bills that result from what is known as balance or “surprise” billing.
- you ever get medical care and see an unexpected bill beyond your deductible or copay, don’t ignore it. You may be victim of prohibited balance billing, often called “surprise billing”. Unfortunately this can occur even if the facility seemed in‑network.
What is Balance Billing - and why it’s a problem
Balance billing happens when a healthcare provider bills you for the difference between their full charges and what your insurance plan agrees to pay. This often occurs when you receive care from an out‑of‑network provider, even if the facility itself (like the hospital) is in-network This is typically when an insurance plan will pay for less than what a hospital, doctor, or lab service wants to be paid for a medical bill. These surprise bills commonly appear in emergencies or specialized care. Examples of this will often be such as anesthesiologists, radiologists, or hospitals that give urgent care. As in these types of situations the patient often had no choice in selecting an out‑of‑network provider.
Federal protections to stop balance billing: The No Surprises Act
Enacted as part of the Consolidated Appropriations Act of 2021, the No Surprises Act took effect with service dates beginning January 1, 2022 and protection rules implemented through October 2022 final regulations. How it protects you is as follows.
Emergency services:
If you receive emergency care, including at an ER, from an out-of-network provider or facility, you can only be charged your plan’s in-network cost-sharing (e.g. copay, deductible). No matter where/when it occurs, any excess billing (balance billing) is prohibited by the Act.
Non‑emergency services at in-network facilities:
If you get care from an out-of-network provider at an in-network hospital or surgical center (like anesthesiologists or radiologists), you are protected by the No Surprises Act unless you have given written, informed consent at least 72 hours ahead of time and knowingly waived protections
Cost-sharing parity:
Insurers can't charge more cost-sharing for out-of-network services than in-network without notifying you and obtaining consent
Air ambulance services:
The law also covers out-of-network air ambulance services, such as a helicopter transportation a patient. However, ground ambulance bills remain largely unregulated at the federal level but there are ways to get help to pay for ambulance costs .
Transparency requirements:
Providers and insurers must keep provider directories current, disclose costs clearly for any type of health care services, and give uninsured patients a Good Faith Estimate before scheduled treatment. Patients have the legal right to dispute bills that exceed the estimate by $400 or more.
Consumer Protection Laws:
The person does not need to pay this amount of any surprise bill, and in some states this is being regulated or may even be illegal for the medical provider to demand payment. Fearing the calls of a debt collector, and uncertain what to do, the patient often times pays up without asking for help. Find how to get help from medical debt collectors . If/when any of this occurs, then your insurer must apply the Qualifying Payment Amount (QPA). This is in effect a median in-network rate for similar services in your area. This will be the amount to be charged as the basis for cost-sharing and direct billing to providers. Read more on the federally mandated No Surprises Act here https://www.cms.gov/nosurprises . Balance billing will most frequently occur with medical providers that participate in a managed-care network. It can occur from a doctor, surgeon, or maybe even a pharmacy. It is more common for these providers to believe that the plan's insurer is giving too deep a discount on the medical costs bills or that the insurer is taking too long to pay a bill. So they try to then charge the patient.
How patients can protect themselves from Balance Billing
Despite the law’s No Surprise Act strong protections, gaps and enforcement issues remain , so still be mindful of this issue. There are still instances of underestimates from a health care provider, billing delays, provider consolidation, and poor implementation continue to leave patients unexpectedly liable for large amounts, sometimes thousands even after receiving estimates Always be aware - read the fine print and ask questions . When a hospital or doctor thinks that a health insurer has reimbursed too little for the work or service that was done, federal and state laws will generally bar the medical providers from asking, and especially pressuring medical patients to pay the difference in the medical bill. Instead, the hospitals and doctors should be negotiating and wrangling directly with the insurers for the unpaid bills and debt, as those are the parties that need to pay.
Other keys steps include:
Know your rights:
Under the No Surprises Act, you should never face balance billing for emergency care or out-of-network providers at in-network hospitals unless you explicitly waive protection.
Always ask if providers are in-network:
Do this up front (when possible) before any care is provided. Ask even specialists at in-network facilities. If told they're not, ask for advance notice and refuse unwritten waivers.
Keep documentation:
Save Good Faith Estimates and Explanation of Benefits (EOBs). If the bill exceeds estimate by $400 or more, you have the right to dispute.
Dispute aggressively:
Use open negotiation and, if needed, file for
Federal Independent Dispute Resolution (IDR)
between insurer and provider. You only owe your in-network share, and all billing disputes are decided without involving you financially.
Seek help:
If you're stuck with a surprise bill, contact your state insurance department or consumer protection agency. There are also free legal aid attorneys in all states as well. In case of unresolved complaints, you can escalate to CMS or federal agencies under the No Surprises Act. Many states (in addition to the federal government Act) will also protect insured patients from balance billing practices by all out-of-network doctors and hospitals in emergencies, since the patients usually do not control what doctor of hospital treats them in those situations. If this happens to you, do not pay the bill. Instead, you should contact an attorney, call a medical billing advocate , or contact your state regulator for help with understanding your consumer rights. In addition to the The No Surprises Act, each state has different laws and rules in place, but in almost every single case the consumer will not be responsible for paying.