Surprise Medical Bills and Your Rights

You go to an in-network hospital, do everything right, and weeks later a bill shows up from a doctor you never picked. That's a "surprise bill." A federal law called the No Surprises Act protects you from many of these bills. Here's when it applies, when it doesn't, and what to do if one lands in your mailbox.

What is a surprise bill?

CMS (the federal agency that runs Medicare and Medicaid) explains two terms:

Balance billing: a provider bills you for the part of the bill your health plan doesn't cover. This usually happens with out-of-network providers. If they charge more than your plan's "allowed amount," you may be billed for the difference.
Surprise billing: an out-of-network provider or facility unexpectedly bills you for that leftover balance. It can also mean being charged more than your normal in-network cost-sharing.

CMS says you're more likely to get a surprise bill when you don't get a chance to pick an in-network provider, like during an emergency.

The No Surprises Act in one minute

The No Surprises Act is a federal law that took effect on January 1, 2022. CMS says it protects you from unexpected out-of-network bills for:

Emergency room visits
Non-emergency care related to a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center
Air ambulance services

CMS says these protections apply if you have health insurance through an employer (including a Federal Employees Health Benefits plan), HealthCare.gov or a state Marketplace, or other individual coverage.

You still pay your normal share. When the law applies, CMS says your cost-sharing (your deductible, copay, or coinsurance) for the out-of-network care can't be more than your in-network cost-sharing. (See Health Insurance Terms: Deductible, Copay, and More.)

When the protections apply

Emergency care

CMS says if your plan covers emergency care, the hospital, the providers who treat you there, and an air ambulance that took you there can't charge you more than your in-network cost-sharing for emergency services. "Emergency room" here includes:

Hospital emergency rooms
Independent, freestanding emergency departments
Any hospital department where you might get care to keep you stable after the emergency (called post-stabilization care)

The Department of Labor (DOL) adds that if your plan covers emergency services at in-network hospitals, it must cover the same emergency services at an out-of-network hospital, even if your plan doesn't otherwise cover out-of-network care.

Planned care at an in-network facility

CMS gives an example: your local hospital is in-network, but a doctor who treats you there is out-of-network. You're protected from out-of-network charges for care related to a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center.

DOL mentions providers like anesthesiologists or radiologists as examples of out-of-network providers you might see at an in-network hospital.

Air ambulance

DOL says you're protected from surprise out-of-network air ambulance bills if your plan generally covers air ambulance services.

When the protections usually don't apply

Based on CMS, the federal protections generally don't cover:

Ground ambulances. CMS says ground ambulance services generally aren't covered by the No Surprises Act and can still charge out-of-network rates, unless state law says otherwise. Some states have their own rules.
Non-emergency care at other places, like a doctor's office that isn't a hospital outpatient department, or an out-of-network facility.
Care your plan doesn't cover at all, even if it had been in-network.
Vision-only and dental-only plans (but the protections may apply if vision or dental is part of your health plan).
Short-term limited duration plans and health care sharing ministries.
Fixed indemnity plans, like hospital indemnity insurance. (See Accident, Critical Illness, and Hospital Indemnity Plans.)
Medicare, Medicaid, Indian Health Services, VA health care, and TRICARE. CMS says these programs already have some of their own protections.

Some plans don't cover emergency care at all. If you're not sure, ask your plan.

This is the big catch. For some planned care, an out-of-network provider may ask you to sign a notice and consent form. CMS says signing it means you agree to out-of-network care and give up your surprise-billing protections. You will likely pay more.

What CMS says about the form:

Signing is your choice. If you don't sign, the provider may refuse non-emergency or post-stabilization care, and you may need to reschedule with an in-network provider.
It must be separate from your other paperwork, given in advance, and offered in the format you prefer (paper or email).
It must include an estimate of what the out-of-network care might cost.
You shouldn't get one in the emergency room for emergency services.
Some providers can never ask you to sign one, including emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, and diagnostic services like lab work.

Before you sign, CMS says you can call the No Surprises Help Desk (below) with questions, or talk to your insurer, your provider, or a patient advocate.

No insurance, or not using it? Ask for a good faith estimate

If you don't have insurance, or you choose not to use it for a service, CMS says providers usually must give you a good faith estimate of expected charges:

You get one when you schedule care at least 3 business days ahead, or when you ask for one.
You won't get one during emergency care.
Each estimate covers one provider or facility. For surgery, CMS suggests asking both the surgeon and the hospital.
Get it in writing and save it. You need it to use the dispute process.
If a provider's bill is at least $400 more than its estimate, you may be able to dispute the bill. CMS says you must start within 120 days (about 4 months) of getting the first bill.

Got a bill that looks wrong? Steps to take

These steps come from CMS's medical bill rights pages.

Don't rush to pay. CMS says you should get an Explanation of Benefits (EOB) from your plan before the bill (except a copay or coinsurance you may pay at the visit). An EOB is not a bill. If you never got one, call your plan to make sure a claim was sent.
Compare the EOB to the bill. The amount your EOB says you owe should match your bill. If it doesn't, contact the provider's billing office.
Ask for a detailed (itemized) bill listing each item or service.
Check for errors, like services you didn't get or being billed twice. You can ask for your medical records and compare. (Some providers charge a records fee.)
Call your health plan. It may be able to fix billing errors with the provider.
Appeal if needed. If the EOB matches the bill but you still think it's wrong, CMS says you can file an internal appeal with your plan, then an external review.
Get help. CMS points to your state's Consumer Assistance Program or a patient advocate.
Report it. If you think a provider, facility, or insurer isn't following the law, you can submit a complaint to the No Surprises Help Desk.

CMS notes that sending a complaint doesn't erase what your EOB says you owe.

The No Surprises Help Desk

Phone: 1-800-985-3059. CMS lists phone support 7 days a week and help in over 350 languages.
Online: CMS's medical bill rights site (cms.gov/nosurprises/consumers) has a complaint form and an "action plan" tool.

Questions to ask

Before planned care:

Is this hospital or surgery center in my plan's network?
Will any doctors who treat me (like the anesthesiologist) be out-of-network?
Will anyone ask me to sign a notice and consent form? Can I see it ahead of time?
If I'm not using insurance: can I get a good faith estimate in writing from each provider?

After a bill arrives:

Does this bill match my EOB?
Was this care covered by the No Surprises Act? (Ask your plan.)
Can I get an itemized bill?
How do I file an appeal, and what's the deadline?

A simple example

Made-up example: Dana has knee surgery at an in-network hospital. The anesthesiologist turns out to be out-of-network. Later, Dana gets a bill for the full difference between the anesthesiologist's charge and what the plan paid. Under the No Surprises Act, anesthesiologists can't ask patients to waive their protections, so Dana should only owe her in-network cost-sharing. She compares the bill to her EOB, calls the billing office, and calls the No Surprises Help Desk when the bill isn't fixed.

Quick tips

Check the EOB first, then the bill.
Read before you sign any form about out-of-network care.
Ask for estimates in writing if you're paying yourself, and keep them.
Watch deadlines, like the 120 days to dispute a bill against a good faith estimate.
Ground ambulance bills aren't covered federally. Check your state's rules and call the ambulance company.