Ensuring fair billing .
By Rachel Koshy
The No Surprises Act (NSA) is a federal law that protects you from surprise medical bills, especially in situations like emergencies or when you receive care from out-of-network providers at in-network facilities. A Good Faith Estimate (GFE) is a document provided by healthcare providers that gives you an estimate of what you'll likely need to pay for your medical care. It helps you understand your financial responsibilities upfront, so you can make informed decisions about your healthcare. Together they ensure fair billing practices by healthcare providers.
What are your rights and protections against surprise medical bills?
When you need emergency care or receive treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center, you're shielded from balance billing. This means you shouldn't be charged more than what your insurance plan typically requires you to pay, such as copayments, coinsurance, and deductibles.
What is "balance billing" or "surprise billing"?
When you visit a doctor or a healthcare provider, you're often responsible for certain costs that aren't covered by your insurance, like copayments or deductibles. If you see a provider who isn't part of your insurance network, they may charge you more for their services. This additional charge is called "balance billing," and it can be much higher than what you'd pay for the same service from an in-network provider. Surprise billing happens when you're unexpectedly billed for out-of-network services, often in situations like emergencies or when you visit an in-network facility but are treated by an out-of-network provider.
You're protected from balance billing for:
1. Emergency services: If you have a medical emergency and receive care from an out-of-network provider or facility, you'll only be billed for what you would normally pay for in-network services, such as copayments and deductibles. You can't be balance billed for these emergency services. This protection also extends to any services you may receive after your condition stabilizes, unless you explicitly agree to be billed for them.
2. Certain services at in-network facilities: Even if you receive services from out-of-network providers at in-network hospitals or ambulatory surgical centers, they're limited in how much they can bill you. For specific services like emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services, these providers can't balance bill you. If you receive other types of services at these facilities, out-of-network providers can't balance bill you either, unless you agree to it in writing.
In situations where balance billing isn't allowed, you have additional protections:
You're only responsible for paying your share of the cost, like copayments, coinsurance, and deductibles. Your insurance plan will cover any additional costs directly.
Your insurance plan must cover emergency services without requiring prior authorization, even if they're provided by out-of-network providers.
Your insurance plan must base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility, and it must show that amount on your explanation of benefits.
Any amount you pay for emergency services or out-of-network services will count toward your in-network deductible and out-of-pocket limit.
If you believe you've been incorrectly billed, speak to your provider or you can contact your state's insurance regulatory authority for assistance. The federal phone number for information and complaints is: 1-800-985-3059
For more information about your rights under federal law, you can visit the Centers for Medicare & Medicaid Services (CMS) website (www.cms.gov/nosurprises).