What are your rights against a surprise medical bill?

Balance billing happens when an out-of-network provider bills you for the difference between their charge and what your insurer paid. The classic scenario is an emergency room visit at an in-network hospital where the treating physician, the anesthesiologist, or the radiologist is not in your network, a situation you had no ability to check or control. The federal No Surprises Act, effective January 2022, prohibits this for most emergency services, for air ambulance services, and for non-emergency care delivered by out-of-network providers at in-network facilities. In those situations you owe only what you would have owed in network, and any remaining dispute is resolved between the provider and the insurer through an independent process rather than being your problem.

The protections have edges worth knowing. Ground ambulance services were largely excluded from the federal law, which is a significant gap since ambulance balance billing is common, though a number of states have their own protections that fill it. Patients can waive the protections in limited non-emergency circumstances by signing a consent form at least 72 hours in advance, and signing that form is generally against your interest. The law also requires uninsured and self-paying patients to receive a good faith estimate in advance, and provides a dispute process if the final bill substantially exceeds it.

What to do when a bill arrives that looks wrong. Request an itemized bill and your explanation of benefits, and compare them, because billing errors are common and duplicate charges appear regularly. If it looks like prohibited balance billing, say so in writing to the provider and your insurer, and file a complaint with the federal No Surprises Help Desk or your state insurance regulator. Do not pay a disputed balance to make it go away, since payment can complicate the dispute. And know that hospital financial assistance policies are required for nonprofit hospitals and are frequently available well above the income levels people assume, but generally must be applied for rather than offered.