Surprise Medical Bills: Your Rights Under the No Surprises Act
What is a surprise medical bill?
A surprise bill may arise when an out-of-network provider treats a patient who expected in-network care, such as an anesthesiologist at an in-network hospital. It can also arise from emergency care. Your cost depends on the service, plan, and applicable protections.
Federal protections and exceptions
For people using most types of health insurance, the No Surprises Act protects against certain unexpected out-of-network bills for emergency care, certain non-emergency services at in-network hospitals and other covered facilities, and air ambulance services. For protected services, cost sharing generally must be based on in-network rates. A deductible or coinsurance may still be owed. See CMS medical bill rights and its guidance for insured patients.
Ground ambulances generally are not covered by these federal protections, although state law may help. Protections also depend on the type of plan and setting. For certain services, a provider may ask you to sign a notice and consent form giving up protections; specific rules and exceptions apply. Emergency services and certain specialties cannot use the form to waive protections. Check the CMS guidance before signing.
What to do about a bill
Compare your bill with your explanation of benefits. Contact your insurer and provider with the claim and bill details, and use your plan's appeal process if you believe a claim was improperly denied. If you believe the No Surprises Act rules were violated, submit a complaint to CMS or call the No Surprises Help Desk at 1-800-985-3059.
Two different dispute processes
Federal independent dispute resolution (IDR) is a process for providers or facilities and health plans to settle payment amounts for certain out-of-network services. It is not the process for a patient to dispute their own bill with a provider.
Separately, if you did not have or use insurance and received a good faith estimate, you may qualify for patient-provider dispute resolution when a provider's bill is at least $400 more than that provider's estimate. Other eligibility requirements, a filing deadline, and a fee apply; check CMS for current details.