Surprise billing can occur when a patient receives care at an in-network facility, but from an out-of-network provider. For example, a patient undergoing surgery at an in-network hospital may unknowingly be treated by an out-of-network anesthesiologist. This can leave patients with unexpected medical bills, because insurers pay less for services from out-of-network providers.
Surprise billing is a form of balance billing, when a health care provider bills a patient for the remainder of the balance after health insurance has paid its share.
The No Surprises Act went into effect Jan. 1. It bans surprise billing and out-of-network charges for most emergency services, including emergency care that happens out of network or without prior approval. The new law also bans out-of-network charges and balance bills for certain services, like anesthesiology, from out-of-network providers that occur as part of a patient’s visit to an in-network facility.
Health care providers and facilities will be required to provide a notice explaining these billing protections and who to contact if a patient believes a violation has occurred. For example, patients can file an appeal with their insurance company; file a complaint with the State of Wisconsin Office of the Commissioner of Insurance; or file a complaint with the federal Department of Health and Human Services.
The new law does allow providers to ask patients to sign a waiver granting out-of-network charges in certain non-emergency circumstances. In the absence of a waiver, providers may be allowed to refuse care.
Some health insurance programs, such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, and TRICARE, already had surprise billing protections in place and are exempt from the new law.
According to the Kaiser Family Foundation, the federal government estimates the new law will apply to about 10 million out-of-network surprise medical bills each year.
Related Resource: Read our issue brief, The Financial Toxicity of Cancer.
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