Health Insurance Blog

What is surprise billing? 

The National Association of Insurance Commissioners (NAIC) defines surprise billing as when a patient unknowingly or unavoidably receives health care from providers outside their insurance company’s network and is billed directly for that care. 

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This could have left you with higher costs than if you got care from an in-network provider or facility. 

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In addition to any out-of-network cost sharing you might have owed, the out-of-network provider or facility could bill you or the difference between the billed charge and the amount your health plan paid, unless banned by state law. 

• This is called “balance billing". An unexpected balance bill from an out-of-network provider is also called a surprise medical bill. 

Can this affect me?

In 2022, the No Surprises Act (NSA) took effect. This act covers surprise bills for covered emergency out-of-network services, and surprise bills for covered non-emergency services at an in-network facility. The NAIC states:

If you get health coverage through your employer, a Health Insurance Marketplace or an individual health insurance plan you purchase directly from an insurance company, the No Surprises Act will:

• Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand
• Ban out-of-network cost sharing
• Ban out of network charges and balance bills for certain additional services
• Require that healthcare providers and facilities give you an easy to understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent if required to waive billing protections. You must receive notice of and consent to being balanced-billed by an out-of-network provider. 

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Some health insurance coverage programs already have protections against surprise medical bills. If you have coverage through 

• Medicare
• Medicaid
• TRICARE
• or receive care through the Indian Health Services or Veterans Health Administration, 

You don’t need to worry because you’re already protected against surprise medical bills from providers and facilities that participate in these programs. 

What if I get a surprise bill?

If you’ve received a surprise bill that you think isn’t allowed under the new law, you can 

• Ask for an external review of the company’s decision
• You can also file a complaint with your state department of insurance or with the US Department of Health and Human Services.
• File an appeal with your insurance company

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You still can agree in advance to be treated by an out-of-network provider in some situations, such as when you choose an out-of–network surgeon knowing the cost will be higher. The provider must give you information in advance about what your share of the costs will be. If you did that, you’d be expected to pay the balance bill as well as your out-of-network coinsurance, deductibles, and/or copays. 

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