Surprise Medical Bills: What the No Surprises Act Covers and What It Doesn't

What a surprise bill is

A surprise bill usually comes from a provider who is out of network when you had no real way to pick someone else. The classic case is an emergency room visit. Another is a surgery at an in-network hospital where the anesthesiologist or radiologist wasn't contracted with your plan.

Before 2022, that out-of-network provider could bill you for the difference between their full charge and what your plan paid. That is balance billing, and it could run into thousands of dollars. Some states, Florida included, had their own protections, but they didn't reach every kind of plan.

The federal No Surprises Act took effect on January 1, 2022. CMS runs the consumer side, and its No Surprises page is the official source for everything below.

Protection 1: emergency care

If you have job-based coverage or an individual plan, including a Marketplace plan, emergency care is protected:

• No balance billing. An out-of-network emergency room or emergency doctor generally can't bill you more than your in-network cost-sharing, meaning your normal deductible, copay and coinsurance.
• No prior approval. Your plan can't require approval before emergency care.
• It counts toward your limits. What you pay counts toward your in-network deductible and out-of-pocket maximum.
• Freestanding ERs and air ambulances. The protections reach freestanding emergency departments and air ambulance services, not just hospital ERs.

The protection lasts until you are stable. After that, an out-of-network provider may ask you to sign a form agreeing to out-of-network billing for follow-up care. Read it before you sign. You can refuse and ask to be moved to an in-network facility, if you are able to travel safely.

Protection 2: out-of-network doctors at in-network facilities

This one fixes the anesthesiologist problem. When you get non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgery center, certain out-of-network providers there can't balance bill you. You pay in-network cost-sharing.

For some services, the provider can't even ask you to give up these protections. That list includes:

• Emergency medicine and anesthesiology
• Pathology, radiology and lab work
• Neonatology
• Assistant surgeons, hospitalists and intensivists

For other non-emergency care, an out-of-network provider can ask you to waive the protections, but only with a written notice and your signed consent, generally given at least 72 hours ahead. You never have to sign it. If you do, you may be agreeing to pay much more.

Protection 3: good-faith estimates if you're paying yourself

If you are uninsured, or you choose not to bill your insurance for a service, providers have to give you a good-faith estimate of the expected charges. You can ask for one at any time. If you schedule care at least three business days ahead, the provider should send one automatically.

Keep it. If the final bill from a provider or facility is $400 or more above the estimate, you can start a patient-provider dispute through CMS. You generally have to start within 120 calendar days of the date on the bill, and there is a small fee. An independent reviewer decides what you owe.

This matters for people between plans, people who pay out of pocket for a planned procedure, and people on certain plan types that sit outside the insured-patient rules.

What the law doesn't cover

This is where people get hurt, so I want to be plain about it.

• Ground ambulances. The federal protections cover air ambulances but not ground ambulances. A ground ambulance company outside your network can still balance bill you under federal law. A number of states have passed their own ground ambulance rules, so check yours.
• Out-of-network care you choose. If you book an out-of-network specialist for an office visit, the law doesn't protect you. On a PPO, the doctor can still bill the difference above what the plan allows.
• Care at an out-of-network facility you picked. The in-network facility protection only applies when the facility itself is in network.
• Every kind of plan. The insured-patient protections apply to job-based plans and individual health insurance coverage. Some other plan types, like short-term plans, are outside those rules. Before you buy any private plan, ask me how surprise billing protections apply to it.
• Signed waivers. If you signed a valid notice and consent form for a non-emergency service, the protections may not apply to that service.

A typical example

Here is how it usually plays out. Someone has knee surgery at an in-network surgery center with an in-network surgeon. They check everything they can think of. A few weeks later, a bill arrives from an anesthesia group they never met, for the full charge minus whatever the plan paid.

Under the No Surprises Act, that anesthesia group is on the list of providers who can't balance bill in this setting and can't ask the patient to waive the protection. The patient should owe only the in-network cost-sharing, the same amount they would have paid if the anesthesiologist had been in network. The fix is usually a phone call to the billing office, an explanation of benefits in hand, and a reference to the law. If that doesn't work, the complaint process below is the next step.

Now change one detail. Same knee, but the patient chose an out-of-network surgeon at an out-of-network center because they liked the doctor. That bill isn't a surprise under the law. On a PPO, the plan pays its share, and the surgeon can bill the rest. That is why picking the network before you pick the plan matters so much.

State laws still matter

Federal law sets the floor. Many states have their own surprise billing laws, and some go further on things like ground ambulances or plans the state regulates. Florida had its own protections years before the federal law. When a bill falls in a gray area, your state insurance department is a good second call after the federal help desk.

How to tell if a bill is a surprise bill

Pull out three documents: the bill, the explanation of benefits from your insurer, and any good-faith estimate you got. Then ask:

1. Was this an emergency, or care at an in-network hospital or surgery center?
2. Is the provider out of network, and did you have a real choice about using them?
3. Is the bill more than the patient responsibility on your explanation of benefits?
4. Did you sign a notice and consent form? If so, was it for a service where waivers aren't allowed?

If the answers point to a protected situation, the bill may be improper.

How to dispute a bill

1. Don't pay it yet. Paying first makes a refund harder to get.
2. Call the provider's billing office. Say you believe the bill violates the No Surprises Act and ask them to reprocess it at in-network cost-sharing. Write down the date, the name and what they said.
3. Call your insurer. Ask them to confirm how the claim was processed and whether the provider is in network. Insurers and providers settle payment disputes between themselves through a separate federal process. You stay out of it.
4. File a complaint. If the bill isn't fixed, contact the No Surprises Help Desk at 1-800-985-3059 or file online through the CMS page. Your state insurance department can also help, especially for state-regulated plans.
5. Appeal a denial. If your insurer denied the claim, you have appeal rights, including an outside review for many decisions.

Keep copies of everything. A surprise bill dispute is a paper fight.

How to avoid surprise bills before they happen

• Check the facility and the surgeon, and ask who else will be involved in your care.
• Ask for the network status of the anesthesiology group before a scheduled surgery.
• Look up in-network urgent care and ER locations near home and work now, while you are healthy.
• Read any form you are handed before a procedure. If it mentions out-of-network billing, slow down.
• Pick a plan with a network that fits your life. My PPO vs. HMO vs. EPO guide explains how networks change your risk.

Where I come in

I don't handle billing disputes for insurers, but I can help you understand what your plan should have paid and point you to the right place to push back. And when you are shopping, I check networks and plan rules so you know where the protections apply and where they stop.

I'm licensed in Florida and 30 other states, and I work by phone or video. Request a quote if you want to compare Marketplace and private plans with the network question answered up front. There is no fee for my help.