How the ‘No Surprises Act’ Protects You from Unexpected Medical Bills

Have you ever done everything right, chosen an in-network hospital, verified your insurance coverage, and still received a surprise medical bill from a provider you never even met?

In this episode of Take Care, Melody Mulaik explains why surprise medical bills used to happen, what changed with the No Surprises Act, and how the law now protects patients from unexpected out-of-network charges. You'll learn when these protections apply, the exceptions you should know about, and what steps to take if you receive a bill that doesn't seem right.

Whether you're preparing for surgery, visiting the emergency room, or simply trying to understand your health insurance benefits, this episode will help you avoid costly surprises and advocate for yourself with confidence.

What You’ll Learn In This Episode: 

• Why receiving an unexpected medical bill isn't always your fault.
• Understanding the difference between in-network and out-of-network providers.
• How the No Surprises Act changed healthcare billing nationwide.
• Emergency care protections every patient should know.
• Hospital-based providers who may not be in your insurance network.
• Good Faith Estimates for uninsured and self-pay patients.
• Practical steps to dispute incorrect medical bills.
• Resources available through the Centers for Medicare & Medicaid Services (CMS).

Resources: 

• No Surprises Act: https://www.cms.gov/nosurprises/ending-surprise-medical-bills
• Centers for Medicare & Medicaid Services (CMS): https://www.cms.gov/ 
• Explanation of Benefits (EOB): https://www.cms.gov/medical-bill-rights/help/guides/explanation-of-benefits 

Timestamps:

00:00 Rachel's question about an unexpected medical bill

00:48 Why did surprise billing used to happen

01:38 What qualifies as a surprise bill

01:52 The No Surprises Act explained

02:17 Emergency room billing protections

02:47 Hospital-based providers and out-of-network charges

03:18 The ambulance billing exception

03:49 Who pays the remaining balance?

04:28 Good Faith Estimates for uninsured and self-pay patients

05:23 What to do if you receive an unexpected bill

06:01 Compare your bill with your Explanation of Benefits (EOB)

06:35 Filing a complaint with CMS

07:02 Final advice and closing

If this episode helped you better understand your healthcare rights, be sure to follow Take Care, leave a review, and share this episode with a friend or family member. Have a healthcare or insurance question you'd like answered on a future episode? Send it in; you might hear it featured in an upcoming episode. 

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Transcript

Melody 0:11

Hey, everybody, and welcome back to Take Care. So got a great question this week. Rachel wrote in and said, "I did everything right. I picked an in-network hospital. My surgeon was in-network. I even called ahead to confirm I was covered. Then weeks later, I get a bill from a doctor I've never met for way more than I even expected. So is this even allowed?" It's a great question, Rachel, and I want to walk you through why this used to happen and what protections actually that you have now under something that's called the No Surprises Act. So here's one thing a lot of people really don't realize is when you go to a hospital or a surgery center, you're not just seeing one provider, right? There's many times there might be an anesthesiologist who's going to put you under anesthesia for that procedure. There may be imaging that gets done that the radiologist is going to read. There might be a pathologist who actually looks at, if you had a biopsy done is looking at those samples, you know, to make determinations about the tissue and things like that. But historically, those providers didn't necessarily have to be in-network with your organization if the facility was in-network. So in other words, if the big organization, the hospital, or the surgery center was in-network, they were kind of left to be able to do what they want to do. So you picked an in-network at a hospital, and you ended up with a bill from someone that was out-of-network. And again, through no fault of your own, that's what's called a surprise bill, right? So you weren't expecting to get that bill from somebody that was out-of-network. So what happened is back in 2022, there was a new law that got implemented, and it's a federal law, so it got implemented at a national level, and it's called the No Surprises Act. And it really is and was designed to put a stop to getting those bills for out-of-network providers, and that's really designed to protect you. So what that really changed for people, for example, is if you go into the emergency room now, and let's say, you get treated by an out-of-network, ER physician. One of the protections now is that you only have to pay for it as if it were an in-network provider. Full stop on that. So that changed. So prior to 2022, if you went in for an ER visit and it was an out-of-network provider, you were stuck with a much higher bill. Now, if you go in, it doesn't matter if they're in-network, out-of-network for emergency room, you are going to pay for that as an in-network provider, again, because of the No Surprises Act. The other thing with it is if you go to a hospital, as an example. And that anesthesiologist or that radiologist happens to be out of network with your insurance company, they can no longer bill you for the difference. You only pay for that as if it is in-network. So again, those surprises that you had in the past where you got that out-of-network bill is now from an in-network standpoint. Now, one of the things that's out there as kind of an exception is ambulance. So if you have an ambulance ride to the hospital, as an example. Unfortunately, if they are out of network, which frankly a lot of them are, with your insurance company, you're still going to be responsible for that out-of-network fee for your ambulance. I wouldn't say, it's necessarily a loophole, but it's a gap in the law because it really doesn't address ambulances, and that's a whole 'nother thing that we can talk about in another episode. So the question is, you know, okay, I've just said well, you only have to pay the in-network. Who pays the difference between that in-network and out-of-network with it? The bottom line for it is not you. That's really between that provider who's out of network and that particular insurance company. So behind the scenes, they negotiate on that, and if they can't come to an agreement, there is a formal dispute process behind the scenes. The important part for you to know is that's really away from your transaction and away from the bill that you get. So you really shouldn't see that, you're not a part of it, and none of that should land on your particular bill. So that's between that provider and the insurance company, et cetera for it. So again, that's between the insurance company, and the provider, but not for you. So, you know, another thing that may come into play is if you're uninsured or you choose not to use your insurance for something, providers are required to give you a written good faith estimate of what a particular service should cost before you get it. So again, it's your right to have that information. So again, whether it's something that you don't have insurance and you're wanting to get a service, they need to let you know, or if you're choosing to not use your insurance because it's a more cost-effective option for you. There's many times that happens with different imaging studies, a lot of different scenarios where that may choose to come in place. But again, you're entitled to what's called a good faith estimate of what those costs are in advance so that you can make an educated decision. And again, you're not getting a bill after the fact that you had no idea, what your financial obligation was going to be. So for the question that Rachel has posed to us is a few things to look at if we're getting that bill, was it for an emergency room or was the care that was provided at a facility that's in-network? And if the answer is yes, then you're likely protected, and you can go and go back to the hospital, the emergency room, et cetera, to get that clarified and get that bill adjusted. And if the bill shows a balance beyond your normal copay, your deductible, your co-insurance, that's one of those red flags that you want to research a little more. So again, we always go and we look at what does our insurance company's website say that we owe versus what does that bill from that provider or that facility say that we owe. And we look to to reconcile that and make sure that we're not getting overcharged for something. And again, talking to your insurance company is really important. Most of what you need, you can find on their website when you look at your explanation of benefits or your claims for that. But if you can't, definitely pick up the phone and call your insurance company to get that additional information. Worst case scenario, if you've looked at everything and you still feel like, "Gee, something's really not right about this scenario," you can file a complaint with the No Surprises help desk. So that's at CMS, which is the Center for Medicare and Medicaid Services. It's free, and that's what it exists for. So, you know, anytime you think about being kind of stuck in the milling of a middle of a billing dispute that you had no part of, it's important to understand what your protections are as it relates to No Surprises Act. Make sure you're getting all the information that you need, getting it from the insurance website or calling the insurer as needed to make sure that you're not inappropriately stuck in the middle. So good luck getting that resolved. Drop me a note and let me know how things worked out. And if anybody else ever has any questions about anything else, please send me a note. All right. In the meantime, take care.