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What is a Surprise Medical Bill?

Surprise Medical Bills

A surprise medical bill is an unexpected bill, often for services received from a health care provider or facility that you did not know was out-of-network until you were billed. Your health insurance may not cover the entire out-of-network cost which leaves you owing the difference between the billed cost and the amount your health insurance paid. This is known as “balance billing.” This bill could be for a service like anesthesiology, radiology or laboratory tests. You may not know that the provider or facility is out-of-network until you are billed.

What should I do if I receive a surprise bill and have a billing disagreement?

Your rights under the No Surprise Act (NSA) depend on whether you have health insurance or if you are uninsured. In either case, you have rights.

If you are insured and your health plan denies all or part of a claim for service, you can appeal that decision. Your plan documents will contain information on the review process and how you request review of your plan’s decision.

As of January 1, 2022, you generally won’t be responsible for balance bills or out-of-network cost-sharing when getting emergency care, non-emergency care from out-of-network providers at certain in-network facilities, or air ambulance services from out-of-network providers. When this happens, instead of you paying for unexpected out-of-network costs, you’ll generally only need to pay your normal in-network costs (like coinsurance, copayments, and amounts paid towards deductibles). The health care provider and your health plan are responsible for negotiating the total payment amount from the plan to the provider through an independent dispute resolution process.

If you are uninsured or self-pay for insurance, As of January 1, 2022, you should receive a good faith estimate of costs for your care from your provider when you either schedule that care or if you call and request the estimate. After you get the care, if you are billed for an amount more than $400 over the good faith estimate and you got the bill within the last 120 calendar days, you can use the new dispute resolution process to determine the final payment amount. This process uses a third-party arbitrator to review the good faith estimate, the final bill, and any other information submitted by your provider or facility.

If you need further assistance, please contact us.

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