Ban on ‘Surprise' Out-of-Network Costs for In-Network Care Takes Effect Jan. 1

The No Surprises Act takes patients out of the financial equation, limiting what they can be billed for out-of-network services to a fee that’s based on in-network charges

A health insurance claim form on a medical bill.
Getty Images

Patients with private health insurance will see the shock of “surprise” medical bills virtually gone starting on Jan. 1, 2022. That's when the No Surprises Act, passed by Congress in December 2020 as part of a coronavirus compromise package, takes effect.

Under the new consumer protections, patients will no longer have to worry about getting a huge bill following a medical crisis if the closest hospital emergency room happened to have been outside their insurance plan’s provider network. They’ll also be protected from unexpected charges if an out-of-network clinician takes part in a surgery or procedure conducted at an in-network hospital. In such situations, patients will be liable only for their in-network cost sharing amount.

Instead, insurers and service providers would submit their billing disputes to an independent dispute resolution process, to haggle over fees, without dragging patients into it.

When an insurer and a service provider disagree over fair payment, either side can initiate a 30-day negotiation process. If they still can’t come to an agreement, they can take the matter to an independent arbitrator.

The arbitrator will use as a guide a set amount intended to balance the value of the medical services provided with goal of keeping costs from ballooning out of control. Clear justification will be required for the final payment to end up higher or lower.

There will also be a new way for uninsured people and patients who pay their own way to get an estimate of charges for medical procedures, as well as a process for them to resolve billing disputes.

Surprise medical bills have been a common problem for people with health insurance, all the more irritating because most patients might have thought they were protected.

The charges can run from hundreds to tens of thousands of dollars and come from doctors and hospitals that are outside the network of a patient's health insurance plan. Even when patients are careful to choose an in-network physician or facility, part of the visit might require ancillary service from providers not covered by their insurance, such as anesthesiologists, radiologists and intensivists, whom the patient did not choose.

About 1 in 5 emergency visits and 1 in 6 inpatient admissions trigger such surprise bills, according to the Kaiser Family Foundation.

Here are key elements of the legislation:

  • Protecting patients from surprise bills arising from emergency medical care. Protections apply if the patient is seen at an out-of-network facility, or if they are treated by an out-of-network clinician at an in-network hospital. In either case, the patient can only be billed based on their plan’s in-network rate, leaving any balance to be settled between insurers and the out-of-network medical providers. The amount billed will also get counted toward their in-network annual deductible.
  • Protecting patients admitted to an in-network hospital for a planned procedure when an out-of-network clinician gets involved and submits a bill. This can happen when a surgeon is called in to assist in the operating room, or if the anesthesiologist on duty is not part of the patient's plan.
  • Requiring out-of-network service providers to give patients 72-hour notice of their estimated charges. Patients would have to agree to receive out-of-network care for the hospital or doctor to then bill them.
  • Barring air ambulance services from sending patients surprise bills for more than the in-network cost sharing amount. Air ambulance charges have become a bigger problem in states where patients have to travel long distances to get to the best hospitals. However, ground ambulance services will not face the same restrictions, and the legislation only calls for more study of their billing practices.

Patricia Kelmar, a director of health care campaigns at U.S. PIRG, warns that if an out-of-network doctor asks you to sign a "Surprise Billing Protection Form," don't do so without reading it fully and having a clear understanding of the full estimate of charges that you are willing to pay.

Additionally, emergency physicians or facilities, assistant surgeons, anesthesiologists, radiologists, hospitalists and intensivists are not allowed to ask patients to sign the form, CNBC reports. Patients who sign the form can dispute bills that are $400 higher than the estimate by filing a complaint or by calling 1-800-985-3059.

Getting an expensive medical bill can be overwhelming, but negotiating with your doctor doesn’t have to be. Here are a few easy ways to see if you can get your medical bills lowered, even if you don’t have insurance.

The Associated Press/NBC
Contact Us