Federal protections
The No Surprises Act, in plain English
Emergency care and out-of-network clinicians at in-network hospitals have federal protections. Here is what counts.
The federal No Surprises Act limits surprise bills in three common situations and creates a dispute process for uninsured patients. It is one of the most useful tools available, and most people do not know it exists.
What it generally covers
- Emergency care. You generally should not be balance-billed by an out-of-network provider for emergency services, and your cost share should be based on in-network amounts.
- Out-of-network clinicians at an in-network facility. For example an out-of-network anesthesiologist or radiologist at your in-network hospital, unless you gave valid advance written consent.
- Good-faith estimates. If you are uninsured or self-paying, providers must give you an estimate in advance.
The uninsured dispute process
If you were uninsured or self-paying, told the provider that, received a good-faith estimate, and the bill is at least $400 more than that estimate, you may be able to use the federal patient-provider dispute process. You generally need to start within 120 calendar days of the first bill. There is a fee, commonly $25, which is taken off what you owe if you win.
How to use it
- Spot it: emergency care, or an out-of-network clinician at an in-network facility.
- Write to the provider and copy your insurer, asking them to withdraw the balance bill and reprocess under the Act.
- Call the No Surprises Help Desk at 1-800-985-3059 if it stalls.
- File a complaint with CMS if it is not resolved.
In our own case study the Act did not apply. None of our bills was a surprise out-of-network bill. We mention it because it is one of the biggest levers available when it does apply, and most people leave it on the table.
Not legal advice. Check the current rules at cms.gov/nosurprises, because the thresholds and processes change.