What is Balance or Surprise Billing?
Balance billing, sometimes called surprise billing, happens when a health care provider (a doctor, for example) bills a patient after the patient’s health insurance company has paid its share of the bill. The balance bill is for the difference between the provider’s charge and the price the insurance company set, after the patient has paid any copays, coinsurance, or deductibles.
Balance billing can happen when a patient receives covered health care services from an out-of-network provider or an out-of-network facility (a hospital, for example). In-network providers agree with an insurance company to accept the insurance payment in full, and don’t balance bill. Out-of-network providers don’t have this same agreement with insurers. Some health plans, such as Preferred Provider Organization (PPO) or Point of Service (POS) plans, include some coverage for out-of-network care, but the provider may still balance bill the patient if state or federal protections don’t apply. Other plans don’t include coverage for out-of-network services and the patient is responsible for all of the costs of out-of-network care. Typically, patients don’t know the provider or facility is out-of-network until they receive the bill.
Medicare and Medicaid have their own protections against balance billing.
Protections in the No Surprises Act
The No Surprises Act applies to health insurance plans starting in 2022. It applies to the self-insured health plans that employers offer as well as plans from health insurance companies. The No Surprises Act protects you from:
- Surprise bills for covered emergency out-of-network services, including air ambulance services (but not ground ambulance services), and
- Surprise bills for covered non-emergency services at an in-network facility.
- A facility (such as a hospital or freestanding emergency room) or a provider (such as a doctor) may not bill you more than your in-network coinsurance, copays, or deductibles for emergency services, even if the facility or provider is out-of-network.
- When you receive non-emergency services from out-of-network providers (such as an anesthesiologist) at in-network facilities, an out-of-network provider may not bill you more than your in-network copays, coinsurance, or deductibles for covered services performed at an in-network facility.
- You can never be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility for care related to emergency medicine, anesthesiology, pathology, radiology, or neonatology—or for services provided by assistant surgeons, hospitalists (doctors who focus on care of hospitalized patients), and intensivists (doctors who care for patients needing intensive care), or for diagnostic services including radiology and lab services.
If your health plan requires you to pay copays, coinsurance, and/or deductibles for in-network care, you’re responsible for those.
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 copays.
Notice of Your Rights
Your health plan and the facilities and providers that serve you must send you a notice of your rights under the No Surprises Act. Consumers may receive a Notice similar to this notice which was created by CMS from their provider or carrier.
If you believe you’ve been wrongly billed by your provider or an insurance company, Iowa residents may contact the Iowa Insurance Division.
You may also contact the Department of Health and Human Services at 1-800-985-3059 regarding how to dispute a medical bill through the federal dispute resolution process.