Resolving billing disagreements
Payment disputes between uninsured (or self-pay) consumers and providers
Starting January 1, 2022, if you’re uninsured (or not using your health insurance) you should receive a good faith estimate of the potential costs for your care from health care providers when you schedule the care, or if you ask for one.
After you get the care, if you’re billed an amount that’s more than $400 over the estimate you got, you can use a new patient-provider dispute resolution process to determine a payment amount.
This process uses a third-party arbitrator to review your good faith estimate, final bill, and information submitted by your provider or facility.
You can use this dispute process if you meet these 5 conditions::
- You’re uninsured or self-pay (meaning you have insurance but don’t plan to have your health insurance pay for the care)
- You got medical items or services on or after January 1, 2022
- You have a good faith estimate from your provider or the facility who provided your care
- You got a bill within the last 120 calendar days
- The difference between the good faith estimate and your bill is at least $400
Insured consumers: What to do if you receive an out-of-network bill
If you have health insurance, 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 if you got these services after January 1, 2022. If you get a surprise bill, you’ll generally only need to pay your normal in-network costs (like coinsurance and copayments).
If you get a bill that you believe violates the new rules, contact the No Surprises Help Desk at 1-800-985-3059 to ask questions or file a complaint.
Consumer rights when a health plan denies a claim
Starting in January 2022, if you think your health plan’s decision not to pay part or all of a claim is in violation of the new surprise billing protections, you can appeal by using the appeals process described in your plan documents and denial notices.
Under the new rights and protections against surprise billing, health plans that cover emergency services must cover the costs of emergency care at an out-of-network hospital just like emergency care at an in-network hospital.
For example, if you go to an emergency room out of your plan’s network, but later the plan denies all or part of the payment because you went to an out-of-network hospital, you can appeal your plan’s decision
Notice and written consent to get out-of-network care
Health plans must cover at an in-network rate any items and services from an out-of-network provider you see at an in-network hospital or ambulatory surgical center, unless they give you notice and get your written consent beforehand to be treated and billed by the out-of-network provider.
If you get a bill at out-of-network rates and you believe the provider or facility didn’t follow the notice and consent rules, you can appeal your plan’s decision.
If you already paid a surprise medical bill
If you got a surprise bill for medical services provided on or after January 1, 2022 and already paid more than your in-network cost share (copayment, coinsurance, or deductible), you can file a complaint.
You can also appeal to your health insurance company or plan, or contact your health care provider to tell them you think you shouldn’t have been billed for more than your in-network charges. Your provider may be able to resolve the issue.