For decades, one of the most terrifying experiences in American healthcare was the "surprise medical bill." A patient would carefully select an in-network hospital for a planned surgery or rush to the nearest emergency department during a trauma event, only to receive a devastating $8,000 bill months later from an out-of-network anesthesiologist, radiologist, or surgical assistant they never met. Today, that predatory practice is illegal under the federal No Surprises Act.
What is the No Surprises Act?
Enacted by the United States Congress, the No Surprises Act creates comprehensive federal consumer protections against surprise balance billing for individuals enrolled in group health plans and individual health insurance:
3 Core Protections Under the Law
- Emergency Medical Services: If you experience an emergency, you can go to any emergency room—regardless of whether it is in your health plan's network. The hospital and emergency physicians cannot bill you more than your in-network copay or coinsurance, and no prior authorization is required.
- Non-Emergency Ancillary Services at In-Network Hospitals: If you have surgery at an in-network hospital, you cannot be balance-billed if the anesthesiologist, pathologist, radiologist, or neonatologist on duty is out-of-network. Your in-network cost-sharing applies automatically.
- Air Ambulance Transport: Patients are protected from exorbitant out-of-network air ambulance charges (which historically averaged $20,000 to $40,000+). Cost-sharing is capped at in-network rates.
How Disputes are Resolved
Under the statute, patients are completely removed from the dispute. If an out-of-network hospital and your insurance company disagree on reasonable reimbursement rates, they must resolve it through the federal Independent Dispute Resolution (IDR) process. The hospital is legally barred from pursuing the patient for the disputed balance.
What to Do if You Receive a Surprise Bill
If you receive a bill from a medical provider that you suspect violates the No Surprises Act:
- Do not pay the bill immediately.
- Contact the provider's billing department and state: "Under the federal No Surprises Act, I am only responsible for my in-network cost-sharing amount."
- Call Prime Health Global's client advocacy desk. Our licensed advisors review the billing codes and submit complaints to the CMS No Surprises Help Desk on your behalf.
