What to Do When You Receive a Surprise Medical Bill

You thought you did everything right. You went to an in-network hospital, you saw a doctor your insurance plan covers, and you paid your copay at the time of service. Then, weeks later, a bill arrives in the mail for an amount you never expected. This is a surprise medical bill, and it can be a source of immense stress and confusion.

Fortunately, you have rights and options. The No Surprises Act, a federal law that went into effect in 2022, provides significant protections against surprise medical bills. As a Board-Certified Patient Advocate, I help clients navigate these situations and fight for fair and accurate billing. Here's what you need to know.

What Is a Surprise Medical Bill?

A surprise medical bill, also known as balance billing, occurs when you receive care from an out-of-network provider at an in-network facility. This often happens in emergency situations when you don't have a choice of providers, or when a provider you didn't choose, such as an anesthesiologist or a radiologist, is involved in your care.

The balance is the difference between what your insurance company pays the out-of-network provider and what the provider charges. The No Surprises Act is designed to protect you from being responsible for this balance in most situations.

Your Rights Under the No Surprises Act

The No Surprises Act protects you from surprise medical bills for emergency services and non-emergency services from out-of-network providers at in-network facilities.

If you have an emergency medical condition, you can't be charged more than your plan's in-network cost-sharing for emergency services, even if you receive care at an out-of-network facility or from an out-of-network provider.

If you receive care at an in-network hospital or ambulatory surgical center, you can't be balance billed for services from out-of-network providers unless you give prior written consent.

What to Do if You Receive a Surprise Medical Bill

If you receive a bill that you believe is a surprise medical bill, don't just pay it. Take the following steps.

Request an itemized bill. Ask the provider or hospital for an itemized bill with all the billing codes listed. This will help you understand exactly what you are being charged for.

Compare the bill to your Explanation of Benefits. Your insurance company will send you an EOB that shows what they paid for the services you received. Compare this to the bill from the provider to see if there are any discrepancies.

Contact your insurance company. Call your insurance company and ask them to review the claim. Explain why you believe it is a surprise bill and that you should be protected under the No Surprises Act.

Contact the provider's billing department. Let the provider know that you are disputing the bill and that you believe it is a violation of the No Surprises Act.

File a complaint. If you are not able to resolve the issue with your insurance company and the provider, you can file a complaint with the U.S. Department of Health and Human Services. You can call the No Surprises Help Desk at 1-800-985-3059 or visit the CMS website to file a complaint online.

How a Patient Advocate Can Help

Dealing with surprise medical bills can be a complex and time-consuming process. A Board-Certified Patient Advocate can be a powerful ally in this fight. We can review your medical bills and EOBs to identify errors, communicate with your insurance company and providers on your behalf, help you file appeals and complaints, and negotiate with providers to reduce your bill.

If you are struggling with a surprise medical bill, you don't have to go through it alone. I am here to provide the expertise and support you need to resolve the issue and protect your financial health.