Receiving medical care can sometimes come with unexpected financial surprises, especially when dealing with out-of-network providers. The federal No Surprises Act aims to protect patients from excessive charges and hidden costs during emergency situations or when receiving care at in-network facilities. This legislation ensures that patients are not unfairly billed beyond their planned costs, such as copayments, coinsurance, or deductibles, providing greater clarity and security in healthcare billing. It also emphasizes the importance of transparency regarding potential costs, empowering patients to make informed decisions about their care.
Your Rights and Protections Against Surprise Medical Bills
The law safeguards patients when they require emergency treatment or are treated by providers outside their insurance network at hospitals or surgical centers that are otherwise in-network. In such cases, individuals should not be subjected to balance billing, which is an unexpected charge for the difference between the provider’s billed amount and what their insurance plan agrees to pay. Instead, patients are only responsible for their usual cost-sharing obligations, including copayments and coinsurance, as if they received care from an in-network provider.
What Is “Balance Billing” (Sometimes Called “Surprise Billing”)?
Balance billing occurs when a healthcare provider charges a patient the difference between their billed amount and the payment covered by insurance. For example, if you visit a doctor or specialist who is not part of your insurance network, you might be billed for the remaining amount beyond what your insurer covers. This can happen even if you received care at an in-network hospital or facility, but the individual provider was out-of-network. Such charges often catch patients off guard, especially during emergencies or urgent situations where choice is limited.
Out-of-network providers have not signed agreements with your health plan, allowing them to bill you for the remaining costs after your insurer’s contribution. These bills can be significantly higher than billed by in-network providers and may not count toward your annual out-of-pocket maximum, increasing your financial burden unexpectedly.
Protections for Emergency and Certain In-Network Services
If you experience a medical emergency, the law limits what out-of-network providers can bill you. They are restricted to charging only your plan’s in-network cost-sharing amount, such as copayments and coinsurance. You cannot be balance billed for emergency services, even if the provider is out-of-network, ensuring you are not financially penalized during critical moments.
This protection extends to specific services received at in-network hospitals or surgical centers. For services like anesthesia, radiology, pathology, or neonatology, if the specialist is out-of-network, they are still prohibited from billing you more than your plan’s in-network costs. However, for other services at these facilities, out-of-network providers can only bill you if you give written consent and waive your protections.
You Are Not Obliged to Waive Your Protections
Patients retain their rights to avoid balance bills by choosing in-network providers and facilities. You are never required to accept out-of-network care, and your healthcare provider must inform you if you are being referred to an out-of-network specialist within the same practice or facility. This transparency allows patients to make informed decisions about their care options.
Interesting:
Additional Protections When Balance Billing Is Not Allowed
When the law prohibits balance billing, your insurer will handle the payment directly to out-of-network providers, and you are only responsible for your standard cost-sharing amounts. The law also mandates that emergency and out-of-network services are covered without prior approval, and the amount you owe is based on what an in-network provider would charge. Furthermore, any payments made for emergency or out-of-network care count toward your deductible and out-of-pocket limits, providing financial relief and predictability.
For further guidance, contact Harvard University Health Services Patient Accounts at (617) 496-8700 or billing@huhs.harvard.edu to clarify your billing details.
Your Right to a Clear Cost Estimate
Federal regulations require healthcare providers to give patients a “good faith estimate” (GFE) of how much their care will cost, especially for non-emergency procedures. This estimate covers all anticipated charges, including tests and medications, helping patients plan financially. If the actual bill exceeds this estimate by $400 or more, you have the right to dispute the charges.
While some costs may be difficult to predict precisely, providers will give the maximum expected charge when necessary. To learn more about your billing rights and how to dispute excessive charges, visit cms.gov/medical-bill-rights. If you believe you have received an incorrect bill, you can contact the No Surprises Help Desk at (800) 985-3059 or the Massachusetts Attorney General’s Office at (888) 830-6277. Additional information is available at cms.gov/nosurprises.
—
Understanding your rights under the No Surprises Act can significantly reduce unexpected healthcare costs and provide peace of mind. For a deeper look into how emerging technologies like artificial intelligence are transforming healthcare, explore what AI actually does for doctors and patients in clinical settings. Additionally, assessing which countries lead in healthcare quality can help contextualize these protections on a global scale via which country actually has the best healthcare system. Stay informed about the latest trends in health tech by reviewing current trends how AI is being used in healthcare right now, and deepen your understanding of data’s role in healthcare improvements through an introduction to big data and its impact on healthcare.