5 Ways You Might Still Get a Surprise Medical Bill
Even with the No Surprises Act and its consumer protections now in effect, you can still get an unexpected bill. Here's what to do.
By Lisa L. Gill
When the No Surprises Act went into effect on Jan. 1, it brought an end to a problem millions of Americans confronted each year–discovering too late that a doctor or treatment facility they did not choose in the first place did not accept their insurance, leaving them on the hook for potentially thousands of dollars.
That is, the new law took care of most of the problem, because it covers doctors and other healthcare workers in emergency rooms, as well as out-of-network hospital providers like anesthesiologists and radiologists who might treat you at an in-network hospital or facility without your prior authorization. But it still does not extend to some healthcare services you might receive, and there are some gray areas.
Part of a larger federal spending bill passed in late 2020, the No Surprises legislation aimed to address the problem of “balance billing”—when a patient receives a medical service from a doctor or in a facility not in their insurer’s network, as can happen in emergency situations, or when you are hospitalized, and are asked to pay out of pocket for it. In the past, patients could be billed for the difference between the in- and out-of-network rates. But now, in most cases, providers must bill you at your in-network rate and your insurer must cover the charge.
“The new law was a landmark win for consumers with insurance,” says Chuck Bell, programs director at Consumer Reports, who has advocated on this issue for years. “For the first time, patients in all 50 states are protected against surprise bills for emergency and scheduled elective care.”
But while a Kaiser Family Foundation analysis of federal numbers estimates that the new law could prevent as many as 10 million surprise medical bills in a year, the law doesn’t apply to everyone and every situation.
For example, the law’s protections do not extend to some tests your in-network doctor might order, won’t apply at all to certain urgent care centers or outpatient facilities and clinics, and at birthing, hospice, or addiction treatment centers. And it may not help if you need to take a ground ambulance.
“Those all can be sources of painfully expensive surprise medical bills as well,” says Patricia Kelmar, healthcare campaigns director at the Public Interest Research Group, a nonprofit consumer advocacy organization.
The law applies to everyone who gets insurance through their job or purchases an Affordable Care Act plan on their own, with just a few exceptions. Notably, it does not protect people with short-term health insurance, which are plans that offer coverage for less than 365 days, says Karen Pollitz, a senior research fellow at Kaiser Family Foundation, a nonprofit focused on health issues. (The law does not affect people on Medicare, Medicaid, or those with insurance through the Veterans Administration or active military covered by TRICARE, because provisions in those government programs already shield them from surprise medical bills.)
Here we’ll detail where you still can’t rely on the new law to protect you, and what you can do to resolve any surprise medical bill you still might get.
Photo: Terry Vine/Getty Images
What the New Law Doesn’t Cover
Many Urgent Care Centers
Not all urgent care centers are what you may think they are. Some are really no more than glorified doctor offices where you can seek treatment for problems that are not life- or limb-threatening with no appointment required, says Jack Hoadley, PhD, research professor emeritus at the Health Policy Institute at Georgetown University. Others are equipped to handle some common emergency services, such as if you can’t breathe or if you have chest pain. Of those, some may be licensed by the state they’re in as emergency service providers.
And the new surprise medical law applies only to those urgent care facilities that are licensed to provide emergency services, says Hoadley, who has written extensively about the No Surprises Act.
Urgent care centers may advertise using the word “emergency,” but they may not be licensed by the state to provide actual emergency care similar to what you would receive at a hospital—and thus are not subject to the new law.
That makes it critical for you to know which type of urgent care center you’re going to, Hoadley says. So it’s best if, before you have an actual emergency, you call several urgent care centers in your area and ask whether they are licensed to provide emergency medical services.
Retail Clinics
Unlike a traditional doctor’s office, retail clinics, which are usually located in drugstores or supermarkets, offer a more narrow set of tests and treatments. CVS, for example, operates more than 1,100 medical clinics in its stores across the U.S., while Walgreens has more than 400.
Your insurance may or may not cover these kinds of retail clinics, and if not, you won’t be protected from any other surprise medical bill that arises from your visit for nonemergency care.
Birthing Centers, Hospice Facilities, and Addiction Treatment Centers
The law is a little murky on these types of facilities if they’re affiliated with a hospital that takes your insurance, Hoadley says. If it is not hospital-affiliated, it probably won’t be covered by the federal law. So your best bet is to first find out whether a facility you’re considering is hospital-affiliated, and whether it accepts your insurance.
Ground Ambulances
Another big exclusion: ground ambulances. More than half of patients insured by a major national health insurer who received ground ambulance transportation from 2013 to 2017 faced a potential surprise bill, typically about $450, according to figures from an April 2020 analysis in the journal Health Affairs.
The problem is that many ambulances operate out of police or fire departments or other government agencies, which in some states or localities are prohibited from contracting directly with insurers, Hoadley says. The complexity around the local nature of ground ambulances was reported by the New York Times as one of the reasons it wasn’t included in the federal law.
The new legislation directs an advisory committee to convene to study the issue further, and that process is still gathering steam, says Hoadley. So for now, federal protections don’t apply.
However, at least 10 states—Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont, and West Virginia—have some level of surprise billing protections around ground ambulances, according to an analysis by Georgetown University researchers for The Commonwealth Fund. For example, Florida and Illinois ban balance billing by both private and public ambulance services, and Colorado prohibits it only for private ambulance companies.
One piece of good news: The new law does protect you against surprise medical bills if you require an air ambulance—both via airplane or helicopter—the cost of which can be in the tens of thousands of dollars.
Photo: Siri Stafford/Getty Images
Surprise Bills at the Doctor’s Office
As before the new law, for non-emergency, non-hospital care you still need to choose in-network doctors or you risk facing a bill. Knowing this, many consumers have become accustomed to confirming in advance that providers they see are in-network.
But don’t assume that all lab tests or diagnostic screenings your in-network doctor orders for you are covered by the new law. To avoid getting a surprise bill, you need to make sure your doctor sends you to in-network facilities and providers for these screenings.
A few states have laws to protect patients even at the doctor’s office, Hoadley says, such as Michigan and New Mexico. Over half of all states have some surprise medical bill limits, according to an analysis for the Commonwealth Fund. (See this map from the Commonwealth Fund for a more detailed look at what your state covers.)
How to Fight a Surprise Medical Bill
Even with the new legislation, there’s still a chance you could accidentally wind up with a surprise medical bill as hospitals and providers adjust to the new rules, says Pollitz at the Kaiser Family Foundation. Here’s what you can do if that happens.
Don’t automatically pay it. Instead, start making calls, Pollitz says. First, contact your insurance company to find out whether the provider has submitted the bill to it yet. If it hasn’t, call the provider or hospital and remind it to submit the bill directly to your insurer. Once it has received it, your insurer should send you what’s known as an EOB, or Explanation of Benefits, that will include the in-network cost-sharing amount you owe for this service. The out-of-network provider is not allowed to bill you for more than that amount, says Pollitz.
Get an itemized bill and look for errors. If the amount you owe still seems high or is unaffordable, ask your insurer for a bill that itemizes the services you received. Look for duplicate charges or charges for procedures, tests, or services you did not get. Report errors to your insurer and the hospital or doctor’s office. It’s estimated by the Patient Advocate Foundation that up to half of all medical bills contain significant errors.
You can also compare the average cost for specific procedures in your ZIP code by looking them up in the healthcare bluebook.org (once there, select the free online tool). Knowing those costs can help you negotiate the bill down further.
File a federal complaint. The new law establishes a national consumer complaint system for surprise medical bills. If you’ve received a surprise medical bill in 2022 that you believe is in error, and you can’t resolve it with the healthcare provider or your insurer, you can file a complaint online or call 800-985-3059 between 8 a.m. and 8 p.m. EST, seven days a week.
Have your medical bills and your insurer’s explanation of benefits and any other supporting documentation ready because you may be asked to provide those as well. While the federal complaint system cannot negotiate your medical bills, it can enforce federal laws, which could, in effect, lower or eliminate your payment.
File a complaint with your state. Thirty-three states have also enacted legislation that, to varying degrees, protects consumers from surprise medical bills. If you are having trouble getting relief from a surprise medical bill you believe to be in error, file a complaint with your state’s Consumer Assistance Program. Here you can find contact information for your state.
You may have special protection if you are uninsured. Under the new law, if you are uninsured, healthcare providers must now provide you with a “good-faith estimate” of what they will charge for your care. And if the final bill is $400 more than that, you can file a complaint with the Centers for Medicaid and Medicare Services. Once you file, the provider can’t send the bill to collections or charge a late fee until the dispute is resolved.
Get help. Go to the website for the Patient Advocate Foundation, a nonprofit group that helps people deal with unaffordable medical bills free of charge, or call it at 800-532-5274. And to learn more about your rights under the new law, go to Ending Surprise Medical Bills, a website maintained by the Centers for Medicare and Medicaid Services.
