• Wiser Medicare

What Is the No Surprises Act?

The ad campaign for the Holiday Inn motel chain was once “The best surprise is no surprise.” The same can also be said of medical bills, where a surprise expense can cost way more than a motel overnight stay. It can wipe out savings.

What’s a surprise medical bill?

Usually it’s a bill that you get from a health care provider that you thought was in your network, but after the fact you find out wasn’t – the surprises are typically for anesthesiology, radiology, or blood work. If you broke your leg on a ski slope the cost to helicopter you out might cost more than the vacation. Let’s say you require surgery and your surgeon is in your network, but the anesthesiologist who’s called in to put you under isn’t. You think your entire procedure is going to be covered but your insurer is only paying the out-of-network rate of the anesthesiology portion of the bill, and charging you the rest, in a process called “balance billing.” But the problem with balance billing is that it leaves you both off balance and wrecks your bank balance. How were you supposed to know that you were being sedated by a non-network anesthesiologist? You were most likely scared out of your wits when you were brought into the hospital – assuming you even were conscious before you were put to sleep. It’s certainly not a time you’re going to be reading your policy’s fine print and shopping around for the best price. But providers and insurers have been getting away with these charges for years. Congress finally did something about it.


On January 1, 2022, the No Surprises Act (NSA) went into effect, to protect consumers from not all, but many, of the unclear, incorrect, and outlandish bills from medical providers and insurance companies. The bill was proposed in the House of Representatives by New Jersey Democrat Frank Pallone, Jr., on July 9, 2019 and received bipartisan passage in December 2020, leaving a little more than a year to begin implementation.


The key provision of the bill was that it would not hold patients responsible for surprise medical bills, in emergency and non-emergency cases where patients were unable to choose a provider in their insurance network. The bill also prohibited some out-of-network providers from billing patients for costs for which the patient did not receive an estimate at least 3 days in advance. Another key provision was to ensure that providers and insurers could resolve payment disputes via an independent dispute resolution (IDR), without forcing the patient to argue with both the provider and the insurer and spend hours on hold while their blood pressure spiked. The patient also no longer had to worry if that air ambulance from the ski slopes was in-network. Knowing this, if you get a bill and want to appeal, check your plan documents as to how to do it.


These new regulations hold if you have a group health plan or group or individual health insurance coverage. If you do not have any health insurance coverage, you still get some protection: Assuming you’re coherent upon your arrival at the health provider, you must be given a “good faith” estimate of what your care will cost before you get the care. Things can change, just like when you bring your car to the mechanic – once the hood is opened, other problems can be found, so the estimate is not a guarantee. If your health care provider, however, bills you for more than $400 higher than your estimate, you may dispute the charges here at the Centers for Medicare and Medicaid Services. The appeal requires a $25 non-refundable fee.


If you do have health insurance, coherence – and/or a health care advocate – still remains important. The health care provider may ask you to sign a consent form to receive out-of-network non-emergency services which will both inform you about your No Surprises protections, but also give you the chance to waive those protections and pay more for out-of-network care. Again, you are supposed to get an estimate. If you choose not to sign the consent form, you will likely have to find an in-network provider to continue your care. Remember, this does not apply to emergency care, only once you’re on the mend.

 




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